Accreditation is a valuable achievement for behavioral health providers. It strengthens your referral and payor relationships, encourages better outcomes, and helps you operate more efficiently. If you have multiple sites, or have recently gone through a merger or acquisition, accreditation also helps you maintain a standardized level of care across all locations and changes.
If you want your behavioral health organization to achieve accreditation, having a robust EHR in place is not a want, but a need. However, addiction treatment and behavioral health practices have been slow to move from paper charts to a fully electronic health record (EHR), compared to other specialties.
If you haven’t made that move to digital yet—or if you are considering a change to your current EHR—there’s no better time than when you’re pursuing accreditation. The right EHR system can help you satisfy the accreditation process requirements and maintain accreditation standards after you’ve been approved, particularly when it comes to documentation.
Clinical Documentation for Accreditation
When it comes to accreditation, the primary role of an EHR is to create and store clinical documentation. This includes timely, accurate details about a medical treatment or test, as well as any assessments and specific services provided to a client.
Accrediting bodies, such as CARF and the Joint Commission, have specific clinical documentation requirements. These include, but are not limited to:
- Client demographic information
- Current or previous medication and its effects
- Laboratory test results
- Interpretive summaries of mental health assessments
- Any training and education provided to clients
- Written individualized, person-centered treatment plans
- Discharge summaries and aftercare plans
This type of clinical documentation supports meeting eligibility requirements, and helps support and justify medical necessity and the level of care determined for a client.
Behavioral health EHR solutions should provide forms for clinical processes and assessment screenings, including options for customized documentation. An EHR can also prompt a professional to provide all required information, ensuring compliance.
Ideally, an EHR can reduce double-data entry by auto-populating known client data across documents, saving staff time and improving efficiency. EHRs also allow providers to aggregate and analyze data to detect issues such as medication errors, or measure treatment outcomes for individuals or groups.
Organizational Documentation for Accreditation
Accrediting bodies also require written documentation for a behavioral health provider’s operations. These include, but are not limited to:
- Strategic plan
- Ethical codes of conduct
- Procedures to address allegations of ethical violations
- Fundraising procedures, if applicable
- Executive compensation policies
- Governance policies regarding board selection, leadership, structure, and performance
- Job descriptions
- Procedures regarding communications, including media relations and social media
- Emergency preparedness and safety plans
- Written descriptions of staff orientation training
EHRs can help maintain this organizational documentation, as well. Effective EHR solutions can provide templates for policies and procedures, as well as the option to submit incident reports and client complaint forms. This can improve operational efficiency as well as encourage accreditation compliance.
Looking for an EHR built just for you? BestNotes software is tailored specifically for behavioral health and addiction treatment providers.
Our documentation features help you record and track all the data you need to run an effective practice. BestNotes solutions are fully HIPAA compliant and automatically update to the latest CARF and Joint Commission requirements. Contact us to request your free demo!