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Review of Quality Assurance Methods to Assist Professional Record Keeping: Implications for Providers of Interpersonal Violence Treatment

NCJ Number
Aggression and Violent Behavior Volume: 19 Issue: 3 Dated: May/June 2014 Pages: 242-250
Kelsey M. Bradshaw; Brad Donohue; Chelsey Wilks
Date Published
June 2014
9 pages
This article reviews current quality assurance methods used in professional record keeping by mental health services systems.
Over the years quality assurance programs have been developed to ensure that case records maintained within mental health services systems adhere to specific standards of care, ensuring that patients receive the quality and level of care that they require. Inadequate maintenance of records can have negative impacts for patients, especially for those suffering from interpersonal violence. This article reviews current quality assurance methods as they pertain to the management of professional mental health records within the context of interpersonal violence. The article discusses the various types of records that should be maintained. These include informed consent documents, intake forms and demographic information, information releases, progress notes, treatment planning, and termination summary. The article also highlights the different formats used in semi-structured progress notes. The article next discusses the various issues that can affect quality assurance methods used for record keeping. These issues include access to records, the influence of legal implications on record keeping, revocation of service payments due to poor record keeping, external auditing of client records, and potential errors and concerns regarding audits. The article also discusses the need for organizations to implement quality assurance programs pertaining to management of behavioral health records. Table and references