TREATMENT RECORD-KEEPING

CIGNA believes well-documented treatment records, whether electronic or paper, facilitate communication, coordination, and continuity of care, and promote the efficiency and effectiveness of treatment. You are responsible for maintaining an adequate clinical record for each member and furnishing CIGNA with clinical data as necessary for utilization review or quality management. CIGNA's record-keeping standards require the member name and identification number on each page in the record. Treatment record entries should be legible, signed in ink with your name and credentials, dated, and maintained in a consistent chronological order within each file. Records should be easily and readily retrievable from a secure environment that protects patient confidentiality.

Our treatment record keeping standards are consistent with those required in the managed behavioral health organization standards of the National Committee on Quality Assurance (NCQA). In addition, our policy on recordkeeping incorporates Centers for Medicare & Medicaid Services (CMS) requirements particular to the treatment of Medicare members.

Your treatment records should include documentation of all contacts with or about your patients. Documentation in the treatment record should include, but is not limited to:
• Key demographic data.
• The presenting problem.
• A full psychological and medical history.
• A mental status evaluation.
• ICD-9 diagnosis.
• Treatment plan with measurable goals.
• All diagnostic and treatment services ordered or provided, directly or through referral.
• With patient consent, evidence of coordination of care with the primary care physician and other involved clinicians, in addition to other record-keeping requirements outlined in CIGNA’s Practitioner Medical Record Review Worksheet.
• For children and adolescents, prenatal and perinatal events and a complete developmental history should be included.
• For members 12 and older, documentation of past and present use of cigarettes and alcohol as well as illicit, prescribed, and over-the-counter drugs.

To assess compliance with our standards, the treatment record-keeping practices of selected high volume practitioners are audited quarterly. As high volume practitioners near recredentialing, we identify patients they have seen in the prior twelve (12) months and 5-7 are selected to audit. A letter is sent to selected practitioners, soliciting blinded copies of the five (5) clinical records and two (2) Employee Assistance Program records that were chosen by for review. Audit results are used to give practitioners feedback (particularly when results are below the 80% performance goal) and to drive organizational quality improvement. We have also found that effective treatment record documentation supports treatment outcomes through improved treatment planning, the monitoring of member progress towards goals, and improved communication in the case management process.

Thorough clinical treatment record-keeping may also reduce potential risk management issues for you by providing a record of the treatment progress along with documentation of informed consent, patient understanding of their rights and responsibilities, and their understanding of the treatment plan.

In states where there are laws regulating the record-keeping process, these laws shall prevail if greater than CIGNA’s minimum standards; if not, CIGNA standards shall apply.

We Want To Hear From You
If you have topics you'd like to see addressed here please let us know. Contact us at NetworkDevelopment@cigna.com and we'll dig into them. We want this brief to be as informative and insightful as possible and to address topics important to our practitioner community.