The Joint Commission's Information Management Standards for Behavioral Health Care and Human Services are part of a broader framework designed to ensure safe, high-quality care through effective documentation, data handling, and communication practices.

• Organizations must maintain accurate, timely, and complete documentation of all care provided.

• Documentation must support the entire care process, including:

• Initial screening and assessment

• Risk assessments (e.g., suicide, abuse, trauma)

• Treatment planning

• Progress notes and outcome tracking

• Documentation formats must be standardized, secure, and retained according to policy.

• Behavioral health organizations are expected to use measurement-based care to evaluate treatment effectiveness.

• Data collection and analysis must be part of ongoing performance improvement efforts.

• Organizations should choose validated instruments for assessments and document improvements.

• Policies must be in place to ensure confidentiality, integrity, and availability of health information.

• This includes physical and electronic safeguards, access controls, and staff training.

• Information must be readily accessible to authorized personnel to support decision-making and continuity of care.