Clinical Documentation for Mental Health Providers
Adequate medical documentation provides the means for measuring the type, frequency and duration of care provided. Under TRICARE, providers are required to keep sufficient clinical records to substantiate that care provided was actually and appropriately furnished and medically or psychologically necessary. TRICARE requires the following mental health provider types must, at a minimum, maintain medical records in accordance with The Joint Commission, the Commission on the Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (CoA) or an accrediting organization approved by the Director, Defense Health Agency (DHA).
- Acute care psychiatric hospitals
- Intensive outpatient programs (IOPs)
- Inpatient/residential substance use disorder (SUD) rehabilitation facilities
- Opioid treatment programs (OTPs)
- Outpatient mental health and SUD treatment
- Partial hospitalization programs (PHPs)
- Psychiatric residential treatment centers (RTCs)
- Psychiatric units within acute care institutions
Clinical documentation should include, but is not limited to, psychiatric and psychological evaluations, physician orders, treatment plans, physician and/or integrated progress notes, and discharge summaries (refer to TRICARE Operations Manual, Appendix A, Definitions).
In addition, across all mental health settings (outpatient mental health and SUD treatment, OTPs, IOPs, PHPs, psychiatric RTCs, psychiatric hospitals, and inpatient/residential SUD rehabilitation facilities), the evaluation report must include assessments using standardized measures for the diagnosis of post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD) and major depressive disorder (MDD). The required standardized measures, to be performed at treatment baseline, 60–120 day intervals and at discharge, include:
- PTSD: PTSD Checklist (PCL)
- GAD: GAD-7 and
- MDD: Patient Health Questionnaire – 8 (PHQ-8)
Notification to referring military hospitals and clinics
As a reminder, providers must notify the referring military hospital or clinic when a TRICARE beneficiary, in the provider’s clinical judgment, meets any of the following criteria:
- Is a potential harm to self, others or mission,
- Is admitted or being discharged from any inpatient mental health or substance use treatment facility,
- Is experiencing an acute medical condition or involved in treatment that interferes with duty, and/or
- Has entered into or is being discharged from a substance abuse treatment program.