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Checklist – Mental Health Private Practice Internal Audit

This is for internal audits in private practice to prepare for external audits.

Room inspection

1.1 Does the client have informed consent about the practices?


1.2 Does the client have a signed release authorization form?


1.3 Does the customer have a payment authorization on file?


1.4 Does the client have an ID on file?


1.5 Does the client have a history form on file?


1.6 Does the client have a client information form on file?


1.7 Does the client have a customer contact form on file?


1.8 Has any layout been done to a good standard?


1.9 Does the client have an ID on file?


1.10 Have the door stop stops been installed?


1.11 Does the client have an intake form on file?


1.12 Does the customer have a credit card authorization form on file?


1.13 Does the client have a policy and service agreement form on file?


1.14 Does the client have a hippa agreement form on file?


1.15 Does the client have a client insurance form on file?


1.16 Does the client have insurance cards front and back on file?


1.17 Does the client have a telehealth consent form on file?


1.18 Does the customer have prescriptions on file?


1.19 If the client is a minor; Does the file have a photo of the minor?


1.20 Does the Doc M suite fit the specs?


1.21 If the client is a minor; Does the file have identification of the legal guardian?


1.22 Is the vanity installed correctly?


1.23 If the client is a separated/divorced minor, etc.; Is there a Custody Agreement – Joint, Legal and Custody form on file?


1.24 Does the graphic have written consent to discuss matters on behalf of the client?

Chart details provided by physician.

2.1 Does the doctor have a consultation note on file?


2.2 Does the doctor have an admission note on file?


2.3 Does the doctor have a treatment plan on file?


2.4 Does the treatment plan have at least 3 goals?


2.5 Does the treatment plan have at least 3 goals?


2.6 Is there a completion note if applicable?


2.7 Does the admission note have a diagnosis and justification?


2.8 Does Progressnote have a diagnosis and justification?

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