Initial Contact & Screening
✓
Document initial contact/referral source and reason for referral
✓
Complete initial screening for appropriateness of services and level of care
✓
Screen for immediate safety concerns (danger to self or others)
✓
Screen for substance use / intoxication and need for withdrawal management
✓
Screen for urgent medical needs requiring immediate attention
✓
Determine eligibility for services based on admission criteria
✓
Document insurance/financial verification and authorization
✓
Provide pre-admission information packet to client/family
Suicide & Risk Screening
✓
Administer validated suicide screening tool (e.g., C-SSRS, PHQ-9 Item 9, ASQ)
✓
Document suicide screening results in clinical record
✓
If positive screen: complete comprehensive suicide risk assessment
✓
Assess for access to lethal means (firearms, medications, etc.)
✓
Assess for history of prior suicide attempts
✓
Assess for current suicidal ideation, plan, and intent
✓
Identify protective factors (reasons for living, social supports)
✓
Determine risk stratification level (low, moderate, high, imminent)
✓
Develop initial safety plan (Stanley-Brown or equivalent) if indicated
✓
Document lethal means counseling provided to client/family
✓
Screen for violence/homicidal risk
Admission & Intake
✓
Obtain and document informed consent for treatment
✓
Review and document client rights and responsibilities
✓
Provide and obtain signature for Notice of Privacy Practices (HIPAA)
✓
Document inquiry regarding advance directives / psychiatric advance directives
✓
Collect and document demographic information
✓
Document emergency contact information
✓
Obtain signed releases of information (ROI) for coordination of care
✓
Provide written notice of grievance/complaint process
✓
Document consent for specific treatments (medication, group therapy, etc.)
✓
Obtain consent for communication with family/significant others
✓
Review program rules, expectations, and schedule with client
✓
Document client orientation to the program/facility completed
✓
Assign primary therapist/counselor and document in record
✓
Develop initial treatment plan at intake addressing immediate needs, preliminary goals, and initial interventions based on presenting problems
✓
Initiate discharge planning at admission (document initial discharge criteria)
Initial Assessment
✓
Document presenting problem / chief complaint in client's own words
✓
Document history of present illness (onset, duration, severity, triggers)
✓
Obtain psychiatric/mental health treatment history
✓
Complete substance use history (substances, frequency, duration, last use, withdrawal history)
✓
Document medical history and current medical conditions
✓
Complete medication reconciliation — list all current medications
✓
Document known allergies and adverse reactions
✓
Assess current mental status (appearance, mood, affect, thought process, cognition)
✓
Screen for trauma history (ACEs, significant traumatic events)
✓
Document social/developmental history (family, relationships, housing, education)
!
Document family psychiatric and substance use history — flagged
✓
Document legal history and current legal status/involvement
✓
Assess educational/vocational history and current functioning
✓
Complete cultural, linguistic, and spiritual assessment
✓
Assess functional status and daily living abilities
✓
Assess strengths, resources, and barriers to recovery
!
Complete nutritional screening — flagged
✓
Complete pain assessment
✓
Assess for abuse, neglect, or exploitation (mandated reporting)
✓
Identify client-stated goals for treatment
Comprehensive Assessment
✓
Complete comprehensive biopsychosocial assessment
✓
Complete or update comprehensive suicide risk assessment
✓
Evaluate for co-occurring mental health and substance use disorders
✓
Administer standardized assessment instruments (e.g., PHQ-9, GAD-7, AUDIT, DAST)
✓
Complete cognitive functioning assessment
!
Assess for psychological testing needs and refer if indicated — flagged
✓
Complete physical health assessment or refer for physical examination
✓
Order and document lab work / drug screening results
✓
Assess for sexual health / reproductive health needs
✓
Complete detailed trauma assessment (if trauma history identified)
✓
Assess motivation for change / readiness for treatment (stages of change)
✓
Assess housing stability and basic needs (food, transportation)
✓
Document clinical formulation narrative integrating all assessment findings
Diagnostic Formulation
✓
Establish DSM-5 diagnostic formulation (all applicable diagnoses)
✓
Document principal/primary diagnosis
✓
Document any co-occurring substance use disorder diagnosis
✓
Document any co-occurring medical conditions relevant to treatment
✓
Document psychosocial and environmental factors (Z-codes)
✓
Determine and document appropriate level of care using ASAM or equivalent criteria
✓
Obtain physician/prescriber review and sign-off on diagnoses (if required by policy)
Treatment / Care Planning
✓
Develop individualized treatment plan with client participation
✓
Document client's active participation and input in treatment planning
✓
Establish measurable, time-limited treatment goals
✓
Establish specific, measurable objectives for each goal
✓
Document evidence-based interventions/modalities to be used
✓
Specify frequency and duration of each service (individual, group, family, etc.)
✓
Develop or update crisis/safety plan addressing identified risk factors
✓
Document plan for coordination of care with external providers
✓
Document referrals to ancillary services (medical, dental, housing, legal, vocational)
✓
Address cultural and linguistic needs in treatment plan
✓
Document client and family/guardian signature on treatment plan
✓
Obtain supervisor/physician review and signature on treatment plan
✓
Identify discharge criteria and estimated length of treatment
✓
Document medication management plan if medications prescribed
Ongoing Treatment & Services
✓
Provide individual therapy sessions per treatment plan frequency
✓
Provide group therapy sessions per treatment plan
✓
Provide family/couples therapy sessions (if part of treatment plan)
✓
Provide psychoeducation groups/sessions per treatment plan
✓
Document medication management visits with prescriber
✓
Complete progress notes for each clinical contact/service within required timeframe
✓
Document progress toward treatment plan goals in each session note
✓
Re-administer standardized outcome measures at scheduled intervals
✓
Conduct ongoing suicide risk monitoring per identified risk level
✓
Update safety plan as needed based on changes in risk
✓
Document any crisis intervention or emergency services provided
✓
Document incident/unusual occurrence reports per policy
✓
Conduct periodic drug screening/monitoring (if clinically indicated)
✓
Document any use of restrictive interventions (seclusion/restraint) if applicable
✓
Document client attendance and participation in treatment activities
✓
Case management services: assist with housing, benefits, community resources
✓
Document any AMA (against medical advice) risk discussions if client non-adherent
✓
Monitor and document medication adherence and side effects
Treatment Plan Reviews
✓
Conduct treatment plan review within required timeframe (per policy, typically every 30 days)
✓
Document client participation in treatment plan review
✓
Assess and document progress toward each treatment goal and objective
✓
Update or modify treatment goals and objectives based on progress
✓
Reassess diagnosis and update if clinically indicated
✓
Reassess suicide/violence risk and update risk stratification
✓
Update safety/crisis plan as needed
✓
Evaluate continued appropriateness of current level of care
✓
Medication reconciliation — update medication list at each review
✓
Document updated discharge criteria and estimated timeline
✓
Obtain client and clinician signatures on updated treatment plan
✓
Obtain supervisor/physician review and co-signature on treatment plan review
Care Coordination & Communication
✓
Coordinate care with primary care physician
✓
Coordinate care with psychiatrist / prescriber (if external)
✓
Coordinate with other behavioral health providers involved in care
✓
Document communication with referral sources
✓
Document coordination with child welfare, courts, or probation (if applicable)
✓
Document family/guardian involvement and communications
✓
Coordinate with schools/vocational programs (if applicable)
✓
Document all care coordination contacts in clinical record
Transition / Level of Care Changes
✓
Assess clinical criteria for level of care change (step-up or step-down)
✓
Document clinical justification for level of care transition
✓
Update treatment plan to reflect new level of care
✓
Obtain authorization for new level of care (if required)
✓
Conduct warm handoff to receiving provider/program
✓
Provide transition summary with relevant clinical information
✓
Complete medication reconciliation at transition
Discharge Planning
✓
Assess client readiness for discharge (discharge criteria met)
✓
Conduct final suicide/violence risk assessment prior to discharge
✓
Develop comprehensive continuing care / aftercare plan with client
✓
Arrange follow-up appointments with outpatient providers
✓
Arrange follow-up appointment with prescriber for medication management
✓
Coordinate referrals to community support services (housing, peer support, 12-step, etc.)
✓
Provide client with written discharge instructions and continuing care plan
✓
Review relapse prevention / wellness recovery plan with client
✓
Update and provide final safety/crisis plan to client
✓
Provide crisis hotline numbers and emergency resources
✓
Complete discharge medication reconciliation
✓
Provide medication education and written medication list to client at discharge
✓
Obtain signed releases of information for continuing care providers
✓
Send clinical summary / transfer documentation to receiving providers
Discharge Summary & Documentation
✓
Complete discharge summary within required timeframe per policy
✓
Document reason for discharge (completion, AMA, administrative, transfer, etc.)
✓
Document final diagnoses at discharge
✓
Summarize treatment provided (types of services, frequency, duration)
✓
Document client's condition and functional status at discharge
✓
Document progress achieved on treatment goals and objectives
✓
Document outcome measure results (pre- and post-treatment scores)
✓
Document final medication list and any medication changes
✓
Document continuing care/aftercare plan and referrals in summary
✓
Document final risk assessment findings at discharge
✓
Clinician signature and date on discharge summary
✓
Supervisor / physician review and co-signature on discharge summary
✓
Administer client satisfaction survey
Post-Discharge Follow-Up
✓
Attempt post-discharge follow-up contact within 7 days (or per policy)
✓
Document follow-up contact attempt(s) and outcome
✓
Assess client engagement with continuing care plan at follow-up
✓
Screen for any current safety concerns at follow-up contact
✓
Provide additional referrals or resources if needs identified at follow-up
✓
Document 30-day post-discharge follow-up attempt (if required by policy)
✓
Close clinical record upon completion of all post-discharge activities
The full chart-audit checklist — 167 TJC/CARF documentation items across 14 phases of care, with gaps flagged inline. Scroll to explore.