Readjustment Counseling Service Vet Center Report
Clinical Record Standards
RCS had established standards for Vet Center counseling records. Counseling records must contain specific elements to ensure that counselors properly document the care provided to veterans. RCS policy requires recurring consultation and record review by supervisory and clinical professionals within and external to Vet Centers.
RCS regional office staff conduct annual clinical reviews of Vet Centers within their
regions. provided Regional
To monitor RCS self-assessment of the quality of services and treatment to veterans, we reviewed the FY 2008 Clinical Quality Review reports. managers reported various deficiencies in record keeping, to include inadequate
identified by RCS were the lack of summaries. A summary of issues with
team leader Vet Centers’
and missing closing is listed in Figure 5.
FY 2008 Aggregated Quality of Record Keeping Data - N = 203
Treatment plans are current, measurable, and relate to identified focus areas.
Evidence of Team Leader reviews of clinical records.
Course of treatment reflected in Progress Notes.
Psychological, sexual trauma, & military history data are complete and appropriate.
Number of Vet
Figure 5. RCS Record Keeping
VA Office of Inspector General