Document Name: / Quality Record Review – Behavioral Health and Corrections
Document Type: / Procedure
Category: / Services and Programs
Sub-Category: / Clinical Procedures
Scope: / Behavioral Health and Corrections
Effective Date: / 1/20/2014
Version Date: / 1/20/2014

Supervision: At minimum,formal supervision for clinical behavioral health staff occurs once a month and is documented and stored electronically on the Staff drive, Behavioral Health Supervision. Recovery Coaches receive supervision a minimum of twice monthly; weekly is preferred.

Chart Review process:

  1. Clinical supervisors conduct a review of clinical documentationmeasured against a set of Key Quality Indicators. Clinical supervisors cannot review their own records.
  2. These chart reviews measure the quality of:
  3. Biopsychosocial Assessments (BPSA)
  4. Individual Plans of Service (IPOS)[Treatment Plans]
  5. Progress Notes
  6. Discharge/Transfer Summaries
  7. Addendums
  8. Reviews
  9. Monthly chart reviews will occur at a minimumof one chart per month per clinician. Chart Audit Review sheets for scoring chart audits have been developed and approved for each program area. Changes to these Review Sheets need approval of the Quality Oversight team. Review sheets are used depending on the clinical staff’s scope of practice
  10. For example:
  11. Therapists are responsible for BPSAs, IPOSs, Progress Notes and Discharge/Transfers. They would use the appropriate tools to measure quality.
  12. Recovery coaches are responsible for Progress notes. Supervisors would use the Progress note tool to measure their quality.
  13. Chart reviews will be chosen randomly and one closed chart will be chosen per staff per quarter.
  14. To randomize the choosing of open chart process a reviewer will look at the first client the clinician sees in their EPM schedule at the beginning of each month.
  15. If the clinician is not responsible for the assessment and/or treatment plan then the reviewer will continue with the next client on that clinician’s schedule until one is found where the clinician completed the assessment and treatment plan.
  16. To randomize the choosing of closed chart process the last discharged chart will be chosen from that clinician.
  17. If the clinician is responsible for the assessment and/or treatment plan then the reviewer will continue with the previous discharged case until one is found where the clinician completed the assessment and treatment plan.
  18. Supervisors will document clinician’s ongoing progress in the Chart Review Tracking sheet. Documentation of Chart Review process is maintained electronically on the Staff drive, Behavioral Health Supervision.
  19. Supervisors meet with their clinical staff and provide feedback on job performance and document this in supervision notes which are filed and a copy sent to the clinician.

1