An Efficient Standardized Method of Maintaining Quality Assurance in Therapeutic Treatment Record Keeping

摘要

Quality assurance (QA) within the field of mental health is the practice of monitoring and reviewing services to ensure adherence to specified standards of care. Agents within State governments and various organizations influence record keeping procedures through ethical guidelines and law. For instance, client records must be maintained for all clients receiving mental health services, including informed consent, releases of information, treatment plans, and progress notes. Accurate and timely record keeping procedures assure quality mental health services. However, professionals sometimes err in the maintenance of client records, which can have a negative impact on services, clients, and practitioners. To assist proper record keeping practices, QA programs have been developed to facilitate training in managing and monitoring records. The effects of QA programs specific to mental health record keeping have yet to be examined in controlled experimental context. Therefore, this study was conducted to empirically develop and initially evaluate a QA program to assist in monitoring records within the context of a mental health clinic. The number of errors in client records committed before and after implementation of the developed QA program was examined. It was hypothesized that the QA program would be feasible to implement and significantly decrease record keeping errors. An intra-class correlation was computed to examine inter-rater reliability, revealing a moderate level of agreement regarding individual errors using the QA Fidelity of Client Records Form. Separate MANOVAu27s indicated significant differences between QA and non-QA records for types of errors but not for errors based on specific record forms. Specifically, QA records exhibited fewer missing forms and missing dates compared to non-QA records. An independent samples t-test revealed significant group differences for total number of errors. Thus, QA records exhibited fewer total errors compared to non-QA records. Chi-square analysis also resulted in significant group differences, indicating QA records were more organized than non-QA records. Correlational analysis revealed significant negative linear relationships between frequency of QA audits and missing forms, missing dates, and total errors. Thus, as QA audits increased the number of missing forms, dates, and total number of errors decreased. Results suggest that the current QA program may assist in reducing errors, and organizing, mental health records. The QA program utilized in the current study was also determined to be cost-effective and feasible, requiring little time to implement. The current study has implications for improvement in client record keeping through the implementation of QA programming within community-based mental health agencies.