The purpose of this review is to assure adherence to clinical standards and assess quality indicators through the provider agency's clinical documentation and practices. This includes a determination of clear and consistent inter-connection among the diagnosis, assessed needs, ITP provisions, and actual services and interventions delivered.
Medicaid Record Review
| # |
MEDICAID RECORD REVIEW |
'Item Score'
Record Review
(Total of all scores for item/number of records reviewed) 1, 3, 5, N/A |
| 1 |
The current Individual Treatment Plan (ITP) reflects the individual's assessed needs and has been updated per consumer's progress and changing needs. |
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| 2 |
There is evidence of changes in or re-evaluation of treatment needs and/or services during periods of sudden changes in functioning or symptoms. |
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| 3 |
Treatment is consumer driven as evidenced in clinical documentation. |
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| 4 |
Treatment provided builds on the identified strengths of the consumer. |
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| 5 |
All treatment needs as identified on the Mental Health Assessment are being addressed in the ITP and in the actual service and are prioritized based on importance/severity. |
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| 6 |
There is congruence between the information in the Mental Health Assessment and the Functional Assessment/ LOCUS/Ohio/Columbia Scales. |
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| 7 |
There is evidence in the clinical record that primary health care coordination and integrated care is occurring with the primary physical health care provider. |
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| 8 |
There is documentation that the provider is assisting the consumer with utilizing natural supports in the community. |
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Non-Medicaid Record Review
| # |
NON-MEDICAID RECORD REVIEW |
Yes / No |
| 9 |
There is documentation that the provider is working to connect the consumer with benefits / entitlements (such as Medicaid benefits). |
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| 10 |
There is documentation that the provider is assisting the consumer with utilizing natural supports in the community. |
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