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Readjustment Counseling Service Vet Center Report

RCS policy22 10 randomly

states that team leaders are required to conduct monthly reviews of

selected

counseling

folders

per

full-time

counselor.

RCS

managers

developed a form that included the “minimal clinical notations” utilized this form to perform our review of their clients’ records. We

requirements. reviewed 140

We client

records (4 non-psychological counseling23 and 136 our findings are listed in Figure 6. RCS managers to exist with the client records.

counseling records24). A summary of acknowledged that problems continue

39/133 41/133

29.3 30.8

59/136

42.9

33/129 32/129

25.5 24.8

32/129 36/129 36/129

24.8 27.9 27.9

30/131 33/84 38/136

22.9 30.3 27.1

Documented by 1st visit to Vet Center 1. Demographic information 2. Mental status assessed 3. Health history 1/136 18/136 23/136 Documented by 3rd visit to Vet Center

  • 4.

    Global Assessment of Function (GAF) score

  • 5.

    Psycho-Social Focus Severity Rating (PSFSR)

score 6. Patient received Rights & Responsibility Documented by 5th visit to Vet Center 7. Military History 7a. Entry/Training 7b. War Zone – Circumstances of assignment to war zone 7c. Trauma/Sex Trauma Events 7d. Homecoming (Describe homecoming) 7e. Impact of military experience

Other Elements

  • 8.

    Treatment plans completed

  • 9.

    Closing summaries (within 90 days of last visit)

  • 10.

    Review of record by team leader

(signed/dated)

Number of Deficiencies

N=136

Criterion

Review of Counseling Records:

Percentage of Deficiencies

0.7 13.2 16.9

Figure 6. Onsite Counseling Record Reviews Note: The denominator changed based on the criterion evaluated.

22 23 RCS Policy Memorandum No. 3-10, Review of Clinical Records, October 2002. Record contains client demographics and DAP (Data, Assessment, Plan) note about the purpose and outcome of the visit to include readjustment counseling services, such as employment and educational counseling, job finding assistance, benefit, etc.

24 Six distinct and separate sections 1) demographic, 2) counseling intake, 3) individual case notes, 4) closing summary, 5) group counseling notes, and 6) medical problem list VA Form 10-1415.

VA Office of Inspector General

14

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