Clinical Chart Review

Clinical Audit Tool

Scoring Taxonomy

Reference system definitions to ensure data interoperability during chart compliance protocols.

Core Formulation

Total Score = (Access × 0.10) + (Documentation × 0.35) + (Quality × 0.35) + (Outcomes × 0.20)

Access

10%

Documentation

35%

Quality

35%

Outcomes

20%

Rating Scale

RatingPtsThreshold
Excellent44.00
Good33.00 - 3.99
Fair22.00 - 2.99
Poor11.00 - 1.99
Absent00.00 - 0.99

Critical Escalation Protocol

Any Q2 Critical Item evaluated poorly immediately requires a documented compliance plan within 30 days due to high-risk situations.

The Golden Thread

AssessmentService GoalsProgress Interventions

Four Scored Domains

Access to Care

Measures timeliness of service delivery against regulatory standards.

10% Weight

Core Criteria

  • A1a — Timeliness of first offered appointment
  • A1b — Timeliness of first completed appointment
  • A2 — Timeliness of assessment completion

Documentation

Evaluates quality and completeness of clinical documentation.

35% Weight

Core Criteria

  • D1 — Assessment dates (header only, no score)
  • D2 — BH Assessment sub-items (DSM-5 Dx, Initial Tx Recommendation, etc.)
  • D3 — Service/Treatment Plan sub-items
  • D4 — Hospitalization risk (conditional)
  • D5 — Progress Notes (up to 10, each rated on 5 dimensions)
  • D6 — Overall progress note quality
  • D7 — Prescriber coordination (conditional)
  • D8 — Care coordination
  • D9 — Transfer documentation (conditional)
  • D10 — Discharge documentation (conditional)

Quality

Assesses clinical practice quality against peer-reviewed standards and OARs.

35% Weight

Core Criteria

  • Q1 — Clinical quality sub-items (Diagnostic Accuracy, Crisis Planning, Treatment Alignment, etc.)
  • Q2 — High risk situations (conditional) — includes critical escalation items
  • Q3 — Overall quality of BH assessment
  • Q4 — Overall quality of service plan
  • Q5 — Integration of medical/BH care (conditional)
  • Q6 — Cultural responsiveness
  • Q7 — Chronic/complex illness management (conditional)

Outcomes

Measures patient progress and treatment outcomes.

20% Weight

Core Criteria

  • O1 — Symptom/functional improvement
  • O2 — Goal progress
  • O3 — Patient engagement
  • O4 — SUD-specific outcomes (conditional on SUD service type)