Clinic Record Review

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Review Date and Time

  Date

• Contact/referral date, screening date, Initial appt, Admission

  Yes

  No

  N/A

1.11

• Screening same day; Appropriate staff oversight; Approriate criteria; Priority Access; Rationale, process for screen out

  Yes

  No

  N/A

1.12

• Assessment, including psychiatric, timely based on need; Single clinician oversight; Staff trained and licensed; culturally competent; Effective hand off of information; Admission time frame

  Yes

  No

  N/A

1.21

• Comprehensive Assessment: Recipient reason Strengths, supports, stressors; Mental Status; Mental health services; trauma; legal; family or significant others; finances; housing; culture; language; developmental; clinical information

  Yes

  No

  N/A

1.22

• Substance abuse screen for all using standardized instrument; further assessement when indicated; substance use issues in environment; home environment assessed for youth; staff trained/qualified

  Yes

  No

  N/A

1.23

• self harm risk screen, assessment when indicated; Analysis, formulation, recommendations; Moderate or High risk response

  Yes

  No

  N/A

1.24

• Violence Risk Screen, assessment when indicated; Analysis, formulation, recommendations; Moderate or High risk response

  Yes

  No

  N/A

1.25

• Medical history and health status reviewed by medical staff; recommendations enacted, AIMS as appropriate

  Yes

  No

  N/A

1.27

• Screened for tobacco use at intake and quarterly; Assessed on readiness to quit; Home environment assessed for youth; staff trained/qualified

  Yes

  No

  N/A

1.31

• Significant others, service providers, agencies identified; Participation of family and SO's sought; Input of caregivers for children; Info from recent MH providers

  Yes

  No

  N/A

2.11

• Plan based on assessment; Objectives with target dates; Specific services, interventions and frequencies

  Yes

  No

  N/A

2.12

• Individualized plan strength based; caregiver involvement (C&A)

  Yes

  No

  N/A

2.14

• Treatment reviews, assessement of progress; Reviewed at least 90 days; Plan revised appropriately; Other routine monitoring and changing of plan as necessary by clinician

  Yes

  No

  N/A

2.15

• Documentation of services per plan; Notes linked to plan and response significant information noted; Prescriber documentation

  Yes

  No

  N/A

2.21

• Safety plan elements; plans for at risk recipients; recipients aware of plan; given a copy; education on community supports; revised as needed

  Yes

  No

  N/A

2.31

• Initial plan within 30 days; Plan and reviews signed timely

  Yes

  No

  N/A

3.11

• Flexibility of scheduling; satisfaction surveys and recipients rights; complaint resolution process; advocacy information available

  Yes

  No

  N/A

3.12

• Primary clinician at admission; changes reviewed; processing of changes

  Yes

  No

  N/A

3.13

• Respect and confidentiality; engagement and retention barriers addressed; cultural awareness in services; follow up on missed appts; treatment process and services discussed; training in E&R

  Yes

  No

  N/A

3.14

• Families have contact information; understanding of confidentiality; efforts to develop communication with family; communication with caregivers

  Yes

  No

  N/A

3.15

• Integrated treatment available and offered by qualified staff; stages of change/treatment

  Yes

  No

  N/A

3.16

• Risk assessment at disengagement; appropriate effort to re-engage; contact with collaterals, clinical consult; written invite to re-engage

  Yes

  No

  N/A

3.17

• Gives advice re: tobacco harms and benefits of cessation; interventions documented; informed of tx options including referral; cessation meds available and offered; monitoring of meds with other treatments; comprehensive approach

  Yes

  No

  N/A

3.21

• Relevant discharge criteria; appropriate services arranged; discharge summary complete; discharge info sent

  Yes

  No

  N/A

4.12

• Recipient services based on need; services delivered by appropriate staff; medication only monitoring procedures

  Yes

  No

  N/A

4.13

• Crisis service provided when open; after hours plan with licensed staff; crisis info available to therapist; follow-up on crisis contacts after hours; contact info to recipient and significant others

  Yes

  No

  N/A

4.14

• cultural and language needs are met; written materials for recipient use are in preferred language; culturally matched clinicians if possible

  Yes

  No

  N/A

4.31

• Information sharing protocols; informed of privacy policies; value discussed, consents sought; evidence of information sharing

  Yes

  No

  N/A

• Other Information

  Yes

  No

  N/A