The Record of Care section of The Joint Commission's behavioral health standards manual relates to how patient information is documented in their medical record. Standards range from ensuring that medical records capture all information about a client to regulations related to the organization auditing their client charts.
Conducting tracers on individuals medical records on a routine basis and during a mock survey is a great way to ensure that all documentation that is required to be in a patient's chart is present, dated, and authenticated by the appropriate staff.
Typically a Joint Commission surveyor will look to trace a client's stay from pre-admission to discharge, auditing assessments, treatment plans, progress notes, and any other documentation that may be present in the client's chart.
I've always considered Treatment Plans to be the low-hanging fruit when it comes to deficiencies on a survey. One clinical team's idea of what a sufficiently measurable objective may differ from a surveyor's, so it becomes pretty easy to earn a deficiency related to a few of the different standards identified in the Record of Care, Treatment and Services (RC) or the Care, Treatment, and Services (CTS) sections of the standards manual.
As an organization, Recovery Consultants has audited thousands of patient medical records. Combine that with participation in dozens of behavioral health surveys and we are left with the experience and education required to work with your clinical team to ensure that information about services delivered to clients is properly documented.
If your organization needs assistance in reviewing or modifying your Records of Care, Treatment and Services, or achieving accreditation through The Joint Commission, click the link below to contact us through our web submission form, or call us anytime at (866) 444-7272.