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 100% of survey complete.

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* 1. Provider reviewing chart: (Please select your name)

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* 2. Provider being reviewed: (Please select their name)

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* 3. Chart #:

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* 4. Date of Review:

Date

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* 5. Is an appropriate visit type note charted? (i.e. Crisis, Clinical Assessment, etc.)

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* 6. Are problems/Symptoms clearly and appropriately recorded?

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* 7. Is individual's current report of situation/ patient's voice evident?

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* 8. Is mental status exam complete, where appropriate?

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* 9. Was the appropriate measurement tool(s) used and scored?

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* 10. Are symptoms and diagnosis consistent?

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* 11. Are risk assessment/ safety issues considered, addressed and documented?

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* 12. Are appropriate ethical/ legal concerns addressed? (i.e. CPS, Duty to Warn, Ethical conflicts, etc.)

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* 13. Was the treatment plan completed and appropriate?

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* 14. Are significant others, PCP, community resources, etc. documented in the plan?

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* 15. Is note content relevant to medical setting on a need to know basis?

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* 16. Should this chart be reviewed by Behavioral Health Director?

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