Clinical Practice and Guidance Review Tool

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.
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.
3 Treatment is consumer driven as evidenced in clinical documentation.
4 Treatment provided builds on the identified strengths of the consumer.
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.
6 There is congruence between the information in the Mental Health Assessment and the Functional Assessment/ LOCUS/Ohio/Columbia Scales.
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.
8 There is documentation that the provider is assisting the consumer with utilizing natural supports in the community.

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).
10 There is documentation that the provider is assisting the consumer with utilizing natural supports in the community.