Title Page

  • Clinician's Initials

  • Chart Details for (Client's Initials)

  • Date of Audit Performed

  • Number of items out of compliance:

Chart Details Provided By Client.

  • Does the client have informed consent on practices?

  • Does the client have authorization of release form signed?

  • Does the client have payment authorization on file?

  • Does the client have identification on file?

  • Does the client have history form on file?

  • Does the client have client information form on file?

  • Does the client have client contacts form on file?

  • Does the client have identification on file?

  • Does the client have intake form on file?

  • Does the client have credit card authorization form on file?

  • Does the client have policies and services agreement form on file?

  • Does the client have hippa agreement form on file?

  • Does the client have client insurance form on file?

  • Does the client have insurance cards front and back on file?

  • Does the client have telehealth consent form on file?

  • Does the client have prescriptions on file?

  • If the client is a minor; does the file have photo of the minor?

  • If the client is a minor; does the file have legal guardian's identification?

  • If the client is a minor with separated/divorced etc.; Is there a Custodial Agreement form - Joint, Legal and Custodial on file?

  • Does the chart have written consent to discuss matters on behalf of the client?

Chart Details Provided by Clinician.

  • Does Clinician have consultation note on file?

  • Does Clinician have intake note on file?

  • Does Clinician have treatment plan on file?

  • Does treatment plan have at least 3 objectives?

  • Does treatment plan have at least 3 goals?

  • Is there a termination note if applicable?

  • Does intake note have diagnosis and justification?

  • Does progressnote have diagnosis and justification?

Explanations of Issues

  • Reason behind issues in report

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