X hits on this document

86 views

0 shares

0 downloads

0 comments

17 / 32

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

documentation

of

treatment

plans,

military

histories,

and

progress

notes.

Other

problems

identified by RCS were the lack of summaries. A summary of issues with

team leader Vet Centers’

record record

reviews keeping

and missing closing is listed in Figure 5.

FY 2008 Aggregated Quality of Record Keeping Data - N = 203

56

27.6

23

11.3

28

13.8

32

15.8

29

14.3

7

3.4

Deficiency cited

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.

Closing Summaries.

Eligibility verification.

Number of Vet

Percentage

Centers with

with

deficiencies

deficiencies

Figure 5. RCS Record Keeping

VA Office of Inspector General

13

Document info
Document views86
Page views88
Page last viewedWed Dec 07 22:30:26 UTC 2016
Pages32
Paragraphs843
Words8383

Comments