Psychiatry
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MILE HIGH PSYCHIATRY
COMPLIANCE DEPARTMENT
AUDIT RECORD


__________________________________________________________________________________________
TREATMENT PLAN

A. Initiation or Revision was done
B. Clinical Necessity is supported by documentation

FINDING: [select name="variable_7" value="Compliant|non-compliant|uncertain|not applicable"]
FEEDBACK
[textarea name="variable_1"]

___________________________________________________________________________________________
CHIEF COMPLAINT:

A. Includes a symptom or diagnosis
B. Supports Clinical Necessity

FINDING: [select name="variable_7" value="Compliant|non-compliant|uncertain|not applicable"]
FEEDBACK
[textarea name="variable_1"]

___________________________________________________________________________________________
DIAGNOSIS CODES:

A. Coded to the highest specificity
B. Includes relevant medical diagnoses
C. Supported by documentation

FINDING: [select name="variable_7" value="Compliant|non-compliant|uncertain|not applicable"]
FEEDBACK
[textarea name="variable_1"]

___________________________________________________________________________________________
ASSESSMENTS:

A. Has corresponding ICD-10 code
B. Status is clearly stated
C. Plan is appropriate based on the status

FINDING: [select name="variable_7" value="Compliant|non-compliant|uncertain|not applicable"]
FEEDBACK
[textarea name="variable_1"]

___________________________________________________________________________________________
PSYCHOTHERAPY:

A. Exact length of time is documented
B. Modality is described

FINDING: [select name="variable_7" value="Compliant|non-compliant|uncertain|not applicable"]
FEEDBACK
[textarea name="variable_1"]

___________________________________________________________________________________________
PSYCHOTHERAPY:

A. Exact length of time is documented
B. Modality is described

FINDING: [select name="variable_7" value="Compliant|non-compliant|uncertain|not applicable"]
FEEDBACK
[textarea name="variable_1"]

___________________________________________________________________________________________
NEXT APPOINTMENT:

A. Scheduled within appropriate amount of time

FINDING: [select name="variable_7" value="Compliant|non-compliant|uncertain|not applicable"]
FEEDBACK
[textarea name="variable_1"]


___________________________________________________________________________________________
TOTAL TIME:

A. Documented clearly
B. Appears to be appropriate length for problem

FINDING: [select name="variable_7" value="Compliant|non-compliant|uncertain|not applicable"]
FEEDBACK
[textarea name="variable_1"]

___________________________________________________________________________________________
SIGNATURE:

A. Signed on the same date as the appointment

FINDING: [select name="variable_7" value="Compliant|non-compliant|uncertain|not applicable"]
FEEDBACK
[textarea name="variable_1"]

___________________________________________________________________________________________
CRITICAL ISSUES:
[checklist name="variable_1" value="Insufficient Documentation|Conflicting Information|Ambiguous Statements|Patient Safety Risk|Service was not Clinically Necessary "]



OVERALL QUALITY RATING:
[radio name="variable_1" value="Exceeds Expectations|Meets Expectation|Needs Improvement|Unacceptable"]

RECOMMENDATION:
[radio name="variable_1" value="Medical Necessity Audit|Cloning Audit|Documentation Training|Coding Education|Corrective Action|Escalate to Psych Director"]
MILE HIGH PSYCHIATRY
COMPLIANCE DEPARTMENT
AUDIT RECORD


__________________________________________________________________________________________
TREATMENT PLAN

A. Initiation or Revision was done
B. Clinical Necessity is supported by documentation

FINDING:
FEEDBACK


___________________________________________________________________________________________
CHIEF COMPLAINT:

A. Includes a symptom or diagnosis
B. Supports Clinical Necessity

FINDING:
FEEDBACK


___________________________________________________________________________________________
DIAGNOSIS CODES:

A. Coded to the highest specificity
B. Includes relevant medical diagnoses
C. Supported by documentation

FINDING:
FEEDBACK


___________________________________________________________________________________________
ASSESSMENTS:

A. Has corresponding ICD-10 code
B. Status is clearly stated
C. Plan is appropriate based on the status

FINDING:
FEEDBACK


___________________________________________________________________________________________
PSYCHOTHERAPY:

A. Exact length of time is documented
B. Modality is described

FINDING:
FEEDBACK


___________________________________________________________________________________________
PSYCHOTHERAPY:

A. Exact length of time is documented
B. Modality is described

FINDING:
FEEDBACK


___________________________________________________________________________________________
NEXT APPOINTMENT:

A. Scheduled within appropriate amount of time

FINDING:
FEEDBACK



___________________________________________________________________________________________
TOTAL TIME:

A. Documented clearly
B. Appears to be appropriate length for problem

FINDING:
FEEDBACK


___________________________________________________________________________________________
SIGNATURE:

A. Signed on the same date as the appointment

FINDING:
FEEDBACK


___________________________________________________________________________________________
CRITICAL ISSUES:




OVERALL QUALITY RATING:


RECOMMENDATION:

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