qa for treatment plansdapnotes 10.28
TRANSCRIPT
QA for A&D Services Treatment Plans, Treatment Plan Reviews, and, Treatment Notes(Supplement to Chart Review Form: FACILITY:
SECTION I Treatment Plan (ITP) / Treatment Plan Review (TPR)1Th e
signatures on the ITP will include the client & clinician. If any of these signatures is missing choose “No” from the “Note Signed?” row and leave the “?.” Also leave the “?”if there is no ITP and signify its absence by typing a “None” in section “B’s” second space.
2 Both the clinician and client signatures must be present. Indicate their presence by choosing the “Yes” or “No” from the “drop-down” in “Note Signed?” row, leaving the “?” if no TPR was present or was “Late.”3Two “Weekly Note” dates can be entered. Under “Note Signed?” row choose “yes” or “no” indicating the presence of the required clinician signature or leave the “?” if no “Weekly Note” was written.
1 Quality Management Program - CONFIDENTIAL
Client#
Initial Tx Plan(ITP)& 10 Week Summary 1 I
TP
10
Wk
10
Wk
10
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
10
Wk
Client A dmission
Date:
A. Dates TP & 10 Week Summary due:
B. Dates Initial Tx. Plan and 10 Week Summary Occurred: Write “Late” or ‘None,” if true, in the second space provided in each column.
C. Were the appropriate signatures present? * ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?
3SECTION II: WEEKLY DOCUMENTATION (Tx notes will be audited at a rate of 1 per week) [This form totals approx. a 24 month LOS) Write the date Tx note is due (1), when written (a) and use “pull-down” in (b) to indicate the presence of the clinician’s signature).1. DateTX NOTEDue1 Weekly
(#
20)
1a. DateTX NOTEWritten
1b. Note Signed? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?
2. DateTX NOTE
Due1 Weekly
(#
40)
2a. DateTX NOTEWritten
2b. Note Signed? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?
QA for A&D Services Treatment Plans, Treatment Plan Reviews, and, Treatment NotesSECTION II: Weekly Treatment Notes: QA for A&D Services Treatment Plans, Treatment Plan Reviews and, Tx Notes
The following types of Tx. notes are possible within any weekly Tx. note. Under “Type Due,” choose the number and “yes” or “no” indicating its presence.(1.) Admission Summary: (yes or no) (2). Weekly Tx. Note: (yes or no)
Section V: DOCUMENTATION TOTALS & PERCENTAGES OF COMPLIANCE WITH THRESHOLDS(The Admission Summary will be dated prior to the ITP. If it is not, check “No.”
Documentation Yes or No # in DCIS # in File: Possible # of: %: Threshold:a. Admission Summary? y nb. Initial Tx. Plan? y n y n y nc. Weekly Treatment Notes y n % 100%d. TPRs y n % 100%e. Monthly Assessments y n NA % 90%
Section IV - TC MONTHLY ASSESSMENT TOTALSMonth Due
Month Written
Month Due
Month Written
Month Due
Month Written
1. 2. 3.. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
2 Quality Management Program - CONFIDENTIAL
3. Date TX NOTE
Due1 Weekly
(#
60)
3a. Date TX NOTEWritten
3b. Note Signed? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?
4. DateTX NOTEWritten
1 Weekly
(8
0)
4a. DateTX NOTE
Due1 Weekly
4b. Note Signed? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?