Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 728. Clinical records, treatment plans, and assessments

7 AAC 43.728. Clinical records, treatment plans, and assessments

(a) A provider of mental health services shall maintain a clinical record of services provided to a recipient. A clinical record must include

(1) an intake assessment that meets the requirements of (e) and (f) of this section;

(2) an individualized treatment plan that meets the requirements of (c) and (f) of this section;

(3) a psychiatric assessment that meets the requirements of (d) and (f) of this section, if the services are provided at a mental health physician clinic;

(4) a functional assessment, if the recipient receives mental health rehabilitation services in a community mental health clinic; and

(5) a progress note for each service for each day the service was provided, signed by the individual provider; the progress note must describe the credentials of the provider, the service provided, the date of the service, the duration of each service, and the recipient's progress toward identified treatment goals; and

(6) the documentation of concurrence in accordance with 7 AAC 43.470 by any interdisciplinary team organized under that section for each extension of a rehabilitation service beyond the limits in 7 AAC 43.727.

(b) A clinical record must include reports of the following services if provided to the recipient and reimbursed to a provider by the division:

(1) a psychiatric assessment provided in a community mental health clinic;

(2) a report describing the evaluation procedure and findings of any psychological testing and evaluation.

(c) An individualized treatment plan must include

(1) information identifying the recipient;

(2) a list of the members of any interdisciplinary team organized under 7 AAC 43.470 participating in the planning and implementation of the plan;

(3) a prioritized summary of the presenting problems and needs as stated by the recipient and identified during the intake and functional assessments;

(4) a summary statement of the strengths and current resources of the recipient;

(5) a diagnosis established through an intake assessment;

(6) clearly stated goals and measurable objectives derived from the intake assessment and functional assessment and designed to accomplish specific, observable changes in skills, symptoms, behaviors, or circumstances that directly relate to a better quality of life for the recipient;

(7) specific interventions, services, or activities that are designed to accomplish the stated goals or objectives, that promote active treatment, and that are medically necessary, as determined in accordance with 7 AAC 43.486;

(8) the frequency and duration of each intervention, service, or activity included within the plan;

(9) identification of the individual provider responsible for implementation of each of the plan's goals, interventions, and services;

(10) locations where the intervention, service, or activity will be provided;

(11) specific time periods for attainment of each goal or objective;

(12) documentation that the recipient or the recipient's representative actively participated in the development of the treatment plan, or if active involvement is not possible, a statement of the reasons for the lack of participation;

(13) signatures of the following individuals, indicating review and approval:

(A) the recipient or the recipient's representative, unless the recipient or the recipient's representative is not willing or able to participate as described in (12) of this subsection;

(B) at least one physician or mental health professional clinician;

(C) the case manager, if one is assigned;

(D) those participating members of any interdisciplinary team organized under 7 AAC 43.470 who have reviewed and approved the plan; and

(14) a description of any need for an additional evaluation or assessment.

(d) A psychiatric assessment must be rendered by a psychiatrist, a physician, a physician assistant, or a psychiatric nurse practitioner.

(e) A psychiatrist or mental health professional clinician must complete a written intake assessment within one week after a recipient's entry into treatment, update the assessment as new information becomes available, and consider current psychiatric assessments, psychological testing and evaluation, and medical evaluations. The intake assessment must include

(1) the recipient's name, date of birth, address, and other identifying information;

(2) the recipient's current living arrangement and status;

(3) information about and the status of the recipient's family or guardian;

(4) an assessment of the strengths and needs of the recipient and the recipient's family;

(5) the recipient's medical and psychiatric history and current status;

(6) the recipient's medication use history and current status;

(7) an assessment of the recipient's use of alcohol and other drugs;

(8) an assessment of the recipient's mental status;

(9) a complete DSM-IV diagnosis, as set out in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition, dated 1994, adopted by reference;

(10) a prognosis for the recipient; and

(11) treatment and service recommendations.

(f) Providers must perform a treatment plan review at least every three months for recipients under age 21 and at least every six months for recipients age 21 and over. The treatment plan review must include

(1) the recipient's name, date of birth, address, and other identifying information;

(2) the date of the review;

(3) the period covered by the review;

(4) any updated or new assessments completed during the review period;

(5) any change in the recipient's diagnosis;

(6) a brief analysis including

(A) the recipient's progress toward each goal established in the individualized treatment plan;

(B) the effectiveness of the strategies or techniques recommended by the mental health professionals treating the recipient;

(C) recommendations for and changes to treatment goals, objectives, strategies, interventions, frequency, or duration;

(D) any change of individual providers, or any recommendation to change individual providers; and

(E) the expected duration of the medical necessity for the recommended changes;

(7) an examination of the recommended individualized treatment plan for

(A) the least restrictive setting and for services that are conducive to normal behavior;

(B) discharge or transition criteria necessary to move the recipient to less restrictive services; and

(C) satisfaction of the recipient and the recipient's legal representative, if any, with the treatment planning process, services provided, and progress toward established goals; and

(8) dated signatures from the

(A) recipient or the recipient's legal representative;

(B) primary mental health professional clinician; and

(C) mental health professionals treating the recipient, with indication of appropriate credentials for any mental health professional clinicians and mental health clinical associates.

(g) Subject to the other provisions of this subsection, a provider may satisfy the recordkeeping requirements of this section for records that contain behavioral health information through electronic records that meet the applicable requirements of 7 AAC 85. Notwithstanding the requirements of this section, a provider may be required to retain paper or paper-based copies of documents under other state or federal law for audit or other purposes. For purposes of this subsection,

(1) "behavioral health information" means information regarding behavioral health services, including

(A) emergency services, including detoxification and acute psychiatric hospitalization; and

(B) prevention, intervention, and treatment services in the areas of mental health and of alcohol abuse and other addictions, including ongoing care and supportive services; and

(2) "paper-based copies" means documents stored on microfilm or microfiche, in tagged image file format (TIFF), portable document file (PDF) format, or in another format that allows for the efficient storage of documents.

(h) If a provider that is awarded a grant under 7 AAC 78 or 7 AAC 81 closes or ceases to exist as a service provider, the provider's records under that grant, including recipient records, are subject to the requirements of 7 AAC 78.255 or 7 AAC 81.185, as applicable.

History: Eff. 5/5/93, Register 126; am 12/31/94, Register 132; readopt 8/7/96, Register 139; am 11/1/2000, Register 156; am 9/23/2004, Register 171

Authority: AS 18.23.100

AS 47.05.010

AS 47.07.030

AS 47.07.040

Editor's note: The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, dated 1994 and adopted by reference in 7 AAC 43.728, may be obtained by writing to the American Psychiatric Association, 1400 K Street N.W., Washington, DC 20005. This manual is also available for inspection at the Department of Health and Social Services, Division of Medical Assistance, 350 Main Street, Suite 412, Juneau, Alaska or 4501 Business Park Boulevard, Anchorage, Alaska.

Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.728 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.