Chart Review Tool
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Revised
County of Los Angeles – Department of Mental Health
Type of Review:
7/23/13
Initial Intake
Provider Number____________ Service Area ____
Annual
Admission Date: ____________________________
Review Date_______________________
Primary Contact_____________________________
Review Period for Annual
____________
(3-month period prior to cycle month)
Supervisor’s Name___________________________
Date of Last Claimed Service
_
_______
Yes = Meets Requirements
No = Requires Follow-Up Corrective Action Plan (CAP)
N/A = Not Applicable
*Items marked with an asterisk (*) are to be completed by an AMHD ONLY
REQUIREMENT
FINDING
CORRECTIVE ACTION PLAN
ADMINISTRATIVE / REQUIRED FORMS
1. Ensure the following DMH forms are present and completed, if applicable:
All present and
□
completed, if
MH 224A Client Face Sheet
a.
□
applicable
MH 224B Open Episode Form (does current diagnosis match the IS diagnosis?)
b.
□
c.
MH 281
Payor Financial Information (PFI) (renewed annually)
□
MH 500
Consent for Services
d.
Missing
□
MH 635
Advanced Health Care Directive (clients over 18 years old)
e.
□
MH 612
Account Tracking Sheet
f.
□
Acknowledgement of Receipt – HIPAA “Notice of Privacy” Form
MH 601
g.
ASSESSMENT (A)
2. a. Is there a complete Assessment (Initial Intake)? OR
Yes
No
Is there a complete Annual Assessment Update (Annual Review)?
Yes
No
b. Is it signed by an AMHD with his/her license number present?
If No to #2, staff must be required to complete the assessment immediately.
3. Is the documentation legible?
Yes
No
4. Are allergies or lack of known allergies documented?
Yes
No
5. For the Initial Intake Review,
Yes
No
a. Is the COJAC form complete
or
(adults)
Is the Self-Evaluation and Parent/Caregiver Questionnaire complete
(child/adol.)
(Under age 11, not required to do substance abuse screener unless substance use suspected).
Yes
No
b. Is the COD Assessment complete, if indicated by the Substance Use/Abuse
sections on either the Adult or Child/Adolescent Assessment forms?
Yes
No
*
6.
Is the diagnosis supported by the information in the Assessment?
AMHD Initials: _____
7. If the Annual Assessment Update (AAU) indicates that the diagnosis has
No change in dx
changed (see item #5 on the AAU) then answer the following:
Yes
No
a. has a Diagnosis Information form been completed? and
Yes
No
b.
is the diagnosis changed in the IS?
If No to # 6 or # 7, staff must be required to correct the disconnect and/or complete necessary documentation immediately.
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