The Practitioner Conection
Volume XXX, 2nd Quarter

COULD YOUR RECORDS PASS AN EAP AUDIT?

CIGNA has found that improved treatment planning and outcomes can be obtained through effective treatment record documentation. Quality clinical record keeping can also reduce risk management difficulties for practitioners. As might be expected, recent audits of EAP providers’ client records revealed some strengths and weaknesses.

Where do providers do a great job?
In general, providers are off to a good start up front. They tend to do a good job assessing the problem. They take good histories, assess risk and substance abuse issues well and identify a general focus for the EAP sessions.

When and where do things fall short?
Sometimes the record falls short fairly quickly when the next appointment is scheduled and the client does not show, or when a next appointment is not even indicated in the record. Sometimes the record just stops with no further documentation. If a participant schedules an appointment and fails to keep it, the practitioner should contact the participant to discuss their intentions and document this follow up call.

What if the participant does continue beyond the initial assessment session?
An initial treatment plan should be established in collaboration with the participant and documented with clearly stated measurable goals. Goals should include timeframes for attainment. Documentation should reflect the participant’s strengths and barriers as well as progress in achieving goals. Homework activities between sessions are an excellent way to work toward achieving goals.

The treatment record also should reflect coordination of care with the primary care physician, or with any other behavioral clinician or provider. CIGNA providers are expected to coordinate care, appropriately transition the participant to any recommended referrals, and confirm that no further assistance is needed through a documented follow up call.

What is the final step?
Case disposition should be documented. The provider is expected to call CIGNA to close the case and to provide case closure information.

More detailed information regarding all of these documentation requirements can be found in the Administrative Guide, which can be accessed through the Medical Management Program on the Provider Home page. The EAP Clinical Assessment Form, which also meets our audit guidelines, can be accessed through the Clinical Resources Link

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