Any healthcare provider with a pen or computer can make an entry in a client’s chart or treatment plan. But it’s the quality of what is being written and documented that speaks to the level of services that are being provided.
At Behavioral Support Services, we strongly believe that patient records should tell a detailed and consistent story from beginning to end. That’s why BSS is more compliant with meeting standards and regulations for patient record-keeping and documentation than any other mental health organization in Central Florida.
Our dedicated case managers, counselors, and therapists care not only about the clients they are helping but the quality of the document they are writing to support the treatment they are providing.
If you come to BSS, you can trust that your assessment, progress notes, and treatment or service plans exceed the highest standards. You can be confident that you are going to get better. And you can believe that we can document what we’ve done.
Building that level of trust in the community serves our clients in other ways, such as when dealing with their insurance companies.
Our commitment to excellence in our documentation enables us to support our clients’ needs. If one of our clients needs continued treatment, we are successful in working with insurance for authorization because the medical necessity is proven in our paperwork.
Ensuring that our documentation supports the services our clients are getting also guarantees a continuum of care should a client need services in addition to what BSS is providing. For example, if we are providing psychological services but the client is getting targeted case management from another provider, that agency can rely on our information to provide targeted services that align with the client’s needs.
Why We’re Different
- We have instituted peer audits. These are done on a regular basis at each level of care and allow targeted case managers, for example, to review a co-worker’s case file. This allows them to learn from what their peers are doing well and to point out examples of what can be improved. We treat these as teachable moments – not punitive – so staff members are not reluctant to point out areas that need improving.
- Program coordinators and their teams audit 100 percent of service plans and assessments. They look to ensure that appropriate goals have been set, that the focus is appropriate, the client’s needs have been addressed, and there is a well-documented plan for the client’s success. If those criteria are not met, the service plans and assessments are sent back for correction.
- We make random cold calls to families to monitor their satisfaction and to assure that the client is receiving the in-home services that have been documented in the progress notes.
- Therapists make up the third element of our integrated care. They deal with the mental and psychological therapeutic causes of mental illness such as trauma or a condition at birth. It’s not uncommon for clients to deal with frustration or anger.
- Each month, our chief of compliance audits a random sample of claims from each department. She reviews progress notes and goals and objectives of the treatment plan. She confirms that milestones are being met and the diagnosis has not changed.
These are just some of the many steps we take to be the industry leader in compliance. Paperwork can be cumbersome. But our staff understands that if an agency wants to audit our files, we can confidently say, “Great, what records do you want to see?”
Compliance goes hand in hand with client care. We have excellent field staff providing phenomenal services to our clients. But we have to prove that we are delivering outstanding services in order to continue providing them.