Policy Manual


Client Record Review      

Type: Procedure                 Category: QA/QI                 Level: Community Care 

Parties: Community Care employees and contractees

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Supporting References: COA Standards G2.06 and G2.07

Parent Effective Date Approval Level Revision Dates Last Reviewed
N/A  1-4-2004  Management Team  none  N/A
Related Document Code Related Document Name Type
13.ME.7 Case Record Review Policy Policy

Procedure:  At least quarterly, each of Community Care's programs will review a sample of open and closed cases. The number of cases to be reviewed for each program will be determined in the following manner: If a service or program has less than 100 consumers, Community Care must review a random sampling of 100% of the cases served at the time of the quarterly review, e.g., if a program has 6 open clients the review would check a ramdom sample of those 6 cases to equal 1/4 of those cases, plus a closed case. If a service or program has 100 or more consumers, Community Care must review 100 of the cases served during that year. The records selected for each review must represent a random section of the clients served. The random sample must include records from each service or program, and must include both open and closed files. (As a basis for random sampling case selection, all Community Care cases are defined as high risk cases.) The record review will consist of a case coordination peer review where reviewers will evaluate the presence or absence of required documents, and the clarity and continuity of such documents, which include, but are not limited to: a. intake and placement forms; b. assessments; c. service plans; d. appropriate consents and authorizations; e. progress or case notes or summaries; f. evidence of quarterly case supervision; g. relevant signatures; h. medical information; i. service outcomes; and j. aftercare plans. A Case Record Review form titled "Client File Quality Assurance Checklist" will be used for this section of the review. The record review will also include a team review of all client services as represented in the client records chosen for each quarterly review. This review will be documented on the "Client Service Quality Assurance Checklist". This review will evaluate the appropriateness and necessity, and effectiveness of the services provided to clients. The criteria evaluated will include, but may not be limited to the following: a. Were the services needed as shown by a needs statement in the service plan; b. Were the prescribed services provided; c. Were the services provided according to a service plan goal; d. Was the service provider named in the plan, and did that named provider or a designee provide the service; e. Were the objectives met according to the identified timeframe; and f. Were the goals met according to the identified timeframe. The review process to be used will involve a team review process. The reviewing team will consist of personnel who are routinely involved in making service decisions. (Staff may be involved in reviews of cases in which they have been directly involved as long as the reviews are conducted by a team.) Information gathered in the quarterly record reviews will be formulated into a report and communicated to area teams and programs for use in the Continuous Quality Improvement Process. Annually, a report will be made available to the governing body and other stake holders. This report will also be used in the development and implementation of the Agency's CQI plan.