Behavioral Health Standard 2.H – Quality Records Management


The program conducts a documented review of the services provided:

  1. At least quarterly
  2. That addresses, as evidenced by the record of the person served:
    1. The quality of service delivery
    2. Appropriateness of services
    3. Patterns of service utilization
    4. Model fidelity, when an evidence-based practice is identified
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The quarterly review is performed:

  1. By personnel who are trained and qualified
  2. On a representative sample of persons served
  3. That includes:
    1. Current records
    2. Closed records
  4. In accordance with an established review process
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When records are selected for review the person responsible for providing the service/treatment is not:

  1. Solely responsible for the selection of his/her records to be reviewed
  2. A reviewer of his/her records
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The records review addresses whether:

  1. The persons served were:
    1. Provided with an appropriate orientation
    2. Actively involved in making informed choices regarding the services they received
  2. Confidential information was released according to applicable laws/regulations
  3. The assessment of the persons served were thorough, complete, and timely
  4. Risk factors:
    1. Were adequately assessed
    2. Resulted in safety plans, when appropriate
  5. The goals and service/treatment objectives of the persons served were:
    1. Based on:
      1. The results of the assessments
      2. The input of the person served
    2. Revised when indicated
  6. The actual services were related to the goals and objectives in the person’s plan
  7. The actual services reflect:
    1. Appropriate level of care
    2. Reasonable duration
  8. The person-centered plan was reviewed and updated in accordance with the organization’s policy
  9. When applicable, the following have been completed:
    1. Transition plan
    2. Discharge summary
  10. Services were documented in accordance with the organization’s policy
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The organization demonstrates that the information collected from its established review process is:

  1. Used to improve the quality of its services through activities
  2. Used to identify personnel training needs
  3. Reported to personnel
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