Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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RTF
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Resident Name, DOA, Planned D/C date , Age, Diagnosis, Reason for admission, Information from the Pre-admission Certification Committee. (584.16, MHL 33.13)
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Informed of rights, MHLS 9.07
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Assessments: thorough and comprehensive, include strengths, needs and recommendations
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Psychiatric asessment
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Social Assessment: cultural assessment, education assessment/barriers to learning
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Medical Assessment: allergies, special needs, educational
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Other Assessments: emotional, recreational nutritional, vocational
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Initial and Comprehensive Treatment plans, Including goals and objs for tx, specific txs to achieve goals and objs. Name of clinical staff member designated as case coordinator, identification of staff members providing specified services, intial d/c goals and criteria to determine continued stay/UR requirements, documentation of resident's participation and significant others, date of next schedule review.
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Progress Notes: relate to treatment objectives, written at least weekly, Notes on education program as determined by IEP, Notes on family/legal guardian involvement.
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Discharge Planning: begins at admission, involves patient, family, collaterals
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Discharge Summaries:prepared within 15 days of d/c or transfer, reflect course of treatment and progress toward stated goals, disposition and aalternate treatment services may be required
