audit tool05-05- san bernardino county（审计tool05-05 -圣贝纳迪诺县）（7页）.docVIP

On S????? Quality Management unit staff, ?????, Ph.D., and ?????, Psy.D., conducted a quality improvement site and chart audit at/of ?????. A sample of ????? Medi-Cal charts was/were reviewed, with an audit period of ?????. This included ????? Medicare charts, ????? adult charts, and ????? charts of children. There were ????? providers currently responsible for charts or providing the bulk of the services in charts at the site, and approximately ????? currently open charts. CHARTS REVIEWED: ????? OVERALL SUMMARY AND IMPRESSIONS: ????? SPECIFIC FINDINGS, COMPLIANCE, AND DISALLOWANCES: ????? % compliance is the percentage of charts reviewed that did not have a violation or disallowance regarding a given standard Items apply equally to clinics and FFS providers, unless otherwise noted. % COMPL STANDARDS, VIOLATIONS, AND DISALLOWANCES ASSESSMENT 1A ????? All sections of Clinical Assessment are completed in the first two months (FFS-before authorization for services is required), including the following-- ????? 1A2 ????? Culture and language are appropriately taken into account in understanding clients problems ????? 1B ????? Presenting problems (including living situation, daily activities, social support) ????? 1C ????? Mental health hx (dates providers of past care, sources of information, relevant family information) ????? 1D ????? Past and present use of tobacco, alcohol, caffeine, illicit, prescribed, and over the counter drugs ????? 1E ????? Medications dosages prescribed in the past ????? 1F ????? Relevant physical health conditions, including update, labs, and consults ????? 1G ????? Allergies and adverse reactions to medicines ????? 1H ????? Client risk to self or others ????? 1 I ????? Clients preferred language for services, sociocultural hx and issues, importance of religion, and sexual orientation concerns ????? 1J ????? For minors, developmental hx, with prenatal and perinatal events 1K ????? Mental status exam ????? 1L ????? Client