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ABC_ Quality Record Review 2021
1.
Date
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Hour
Time
:
Minutes
AM/PM
-
AM
PM
2.
Background Information
Staff Being Reviewed
Client ID
Reviewer
3.
Client File Status
Open
Closed
4.
Orientation
Yes
No
N/A
Was the Resident provided a complete Orientation and signed a client orientation?
Yes
No
N/A
Was the Resident actively involved in making informed choices regarding the services they received?
Yes
No
N/A
5.
Assessment
Yes
No
N/A
Is there an Intake Assessment present and is it thorough, complete, and timely?
Yes
No
N/A
Were risk factors adequately assessed and did they result in safety plans, when appropriate?
Yes
No
N/A
Identify the special needs of the Client in order to form the basis for the Individual Service Plan
Yes
No
N/A
Is the Intake Assessment signed by staff and dated?
Yes
No
N/A
6.
Individual Service Plan
Yes
No
N/A
Are the Individual Service Plan goals and objectives based on the results of the assessment?
Yes
No
N/A
Are the Goals and Objectives revised when indicated?
Yes
No
N/A
Were the actual services related to the goals and objectives?
Yes
No
N/A
Did the actual services reflect the appropriate level of care?
Yes
No
N/A
Did the actual services reflect a reasonable duration?
Yes
No
N/A
Does the Individual Service Plan address the Client's issues and presenting problems?
Yes
No
N/A
If medication is prescribed, is it documented?
Yes
No
N/A
Is the Individual Service Plan updated, signed, and dated by the client and Caseworker?
Yes
No
N/A
Was the Client offered a copy of the Individual Service plan?
Yes
No
N/A
If a Personal Safety Plan was indicated, was it included in Individual service plan?
Yes
No
N/A
7.
Documentation
Yes
No
Are services documented in accordance with agency policy?
Yes
No
Are Progress Notes signed by the provider?
Yes
No
8.
Transition and Discharge
Yes
No
N/A
Was the Discharge appropriate?
Yes
No
N/A
Was Discharge criteria identified?
Yes
No
N/A
Was Discharge Summary, Discharge Progress Note and Transition Plan completed as applicable?
Yes
No
N/A
9.
Referrals
Yes
No
N/A
If a referral is made to another program or organization, was the referral appropriate?
Yes
No
N/A
Is there written evidence of follow-up of the referral by staff?
Yes
No
N/A
10.
Was staff given a copy of the Quality Record Review form for correction and information?
Yes
No
N/A
Yes
No
N/A
11.
Staff has 14 days to complete any corrections and return them to the Facility Program Supervisor or designee.
List of items needed correction:
