- 1. Each page in the treatment record contains the patient’s name or ID number
|
- 2. Each record includes the patient’s DOB, gender, address, employer or school, home and work telephone numbers including emergency contacts, marital or legal status, appropriate consent forms, and guardianship information if relevant
|
- 3. All entries in the treatment record include the responsible clinician’s name, professional degree, and relevant identification number, if applicable
|
|
|
- 5. Significant advice given by telephone is documented.
|
- 6. The record is legible and content/format is uniformed to someone other than the writer. A second surveyor examines any record judged to be illegible by one provider surveyor
|
- 7. Relevant medical conditions are listed, prominently identified, and revised
|
- 8. Presenting problems, along with relevant psychosocial and social conditions affecting the patient’s medical and psychiatric status, are documented
|
- 9. Special status situations, such as imminent risk of harm, suicidal ideation or development potential, are prominently noted, and documented and revised in compliance with written protocols
|
- 10. Each record indicated what medications have been prescribed, the dosages of each and the dates of initial prescription or refills
|
- 11. Allergies and adverse reactions are clearly documented
|
- 12. A lack of known allergies and sensitivities to pharmaceuticals and other substances is prominently noted
|
- 13. A psychiatric history is documented, including previous treatment dates, provider identification, therapeutic interventions and responses, sources of clinical data, relevant family information, results of laboratory tests and consultation reports
|
- 14. A medical history is documented, which may include, previous treatment dates, provider identification, therapeutic interventions and responses, sources of clinical data, relevant family information.
|
- 15. For children and adolescents, prenatal and perinatal events, along with a complete developmental history (physical, psychological, social, intellectual, and academic), are documented
|
- 16. For patients 12 and older, documentation includes past and present use of cigarettes and alcohol, as well as illicit, prescribed, and over-the-counter drugs
|
- 17. A mental status evaluation documents the patient’s affect, speech, mood, thought, content, judgment, insight, attention or concentration, memory and impulse control
|
- 18. A DSM-IV diagnosis is documented, consistent with the presenting problems, history, mental status examination, and/or other assessment data
|
- 19. Treatment plans are consistent with diagnoses and have both objective measurable goals & estimated time frames for goal attainment or problem resolution.
|
- 20. The focus of treatment interventions is consistent with the treatment plan goals and objectives
|
- 21. Informed consent for medication and the patient’s understanding of the treatment plan is documented
|
- 22. Progress notes describe patient strengths and limitations in achieving treatment plan goals and objectives
|
- 23. Patients who become homicidal, suicidal, or unable to conduct activities of daily living are promptly referred to the appropriate level of care
|
- 24. The treatment record documents preventive services as appropriate (e.g., relapse prevention, stress management, wellness programs, lifestyles changes, and referrals to community resources).
|
- 25. The treatment record reflects continuity and coordination of care between the primary clinician, consultants, ancillary providers, and health care institutions
|
- 26. The treatment record documents dates of follow-up appointments and/or missed appointment or, as appropriate, a discharge plan
|
