DMC Audit Tool - Just for Cont Tx & Review of Clt Chart

Q: What treatment documentation areas are included in the DMC audit checklist?

The checklist includes informed materials and participant rights, demographics and admission information, discharge summary criteria, client assessment items, and the individualized client plan or recovery plan with required signatures and coordination details.

Q: What admission and medical necessity items are audited?

Admission audit items include date and type of admission, referral source, health questionnaire, and documentation requirements such as medical necessity with required MD signature and perinatal proof of pregnancy, along with dates tied to birth or term of pregnancy and postpartum treatment.

Q: What does the audit tool review for ongoing progress and services?

It audits service attendance per session, session type (individual or group), and progress notes showing face-to-face updates related to the client plan, including goals, new issues affecting recovery, support provided, and minimum weekly activity hours and noted exceptions.

Sep 2, 2026

Upload by Bill Black

DMC Audit Tool provides a structured checklist for reviewing treatment documentation across multiple workflow stages, including informed consents, admission agreements, participant rights, nondiscrimination and grievance procedures, and discharge requirements. It covers client demographics, admission data, health questionnaire elements, medical necessity and required physician signatures, and perinatal proof documentation. The tool further audits clinical assessment items, individualized care and recovery plans with objectives and action steps, counselor and MD signatures, coordination of care, service attendance, progress notes, and perinatal education certification.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

DMC Audit Checklist Overview

Informed Materials and Participant Rights

Demographics and Admission

Discharge Summary

Assessment and Client Plan/Recovery Plan

Service Attendance and Progress Notes

Perinatal Certification

| Item | Yes | No | n/a | | --- | --- | --- | --- | | 1. **Just for Cont Tx & Review of Clt Chart-MD | | | | | 2. ** DSM CODE: SUD Diag | | | | | INFORMING MATERIALS | | | | | 3. Consents for Treatment | | | | | 4. Admission Agreement | | | | | 5. Participant Rights:
a. Signed & given a copy | | | | | b. Posted for public view | | | | | 6. Statement of Nondiscrimination | | | | | 7. Clt Rights Statement | | | | | 8. Grievance Procedures | | | | | 9. Discharge Appeal Process | | | | | 10. Program Rules and Regs | | | | | 11. Clt Fees | | | | | 12. Access to Treatment Files | | | | | 13. Privacy & Confidentiality | | | | | DEMOGRAPHICS | | | | | 14. Clt ID | | | | | 15. DOB | | | | | 16. Gender | | | | | 17. Race/Ethnic backgrounds | | | | | 18. Address | | | | | 19. Telephone \# | | | | | 20. Emergency Contact | | | | | ADMISSION | | | | | 21. Date | | | | | 22. Type of Admit | | | | | 23. Referral Source & Other Ref | | | | | 24. Health Questionnaire | | | | | 25. ** Med Nec & MD Sig Req; Perinatal Proof of Pregnancy | | | | | 26. * Date of Birth or Term of Pregnancy-Post Partum Tx. | | | | | OTHER | | | | | 27. Documentation of discussions and actions taken re: non-compliance w rules… | | | | | 28. Drug Screen Results, if appl. | | | | | 29. ** Evidence of MD involved in Clt’s Tx (ind note indicates MD review of clt chart) | | | | | DISCHARGE SUMMARY | Yes | No | n/a | | --- | --- | --- | --- | | 30. Criteria for Discharge | | | | | 31. Description of Tx Episode | | | | | 32. Current Usage | | | | | 33. VOC & ED achieved | | | | | 34. Legal Concerns & Obligations | | | | | 35. Reason for Discharge | | | | | 36. Continuing Care Plan written prior to discharge | | | | | 37. Transfers & Referrals | | | | | 38. Participant Comment | | | | | ASSESSMENT | | | | | 39. Social, Econ, Fam Hx | | | | | 40. Education | | | | | 41. Employment Hx | | | | | 42. Criminal Hx & Legal Status | | | | | 43. ** Physical Exam | | | | | 44. AOD Hx | | | | | 45. Previous Tx Hx | | | | | 46. Clt Signature and Date | | | | | 47. Oriented within 72 hrs | | | | | 48. Clt aware of Comm Service inventory | | | | | 49. Referrals made as appro. | | | | | ***CLT PLAN/RECOVERY PLAN | | | | | 50. Clt Plan is Individualized | | | | | 51. State Problems | | | | | 52. Objectives to address Probs | | | | | 53. Action Steps for Objectives | | | | | 54. Target Dates | | | | | 55. Descrip of services, incl typeof counseling &freq. | | | | | 56. Assignment of Primary Counselor | | | | | 57. Clt Participation doc’d | | | | | 58. Complete 14 days from Adm | | | | | 59. Review min. every 14 days | | | | | 60. Review/revise every 90 days | | | | | 61. Signed by Counselor | | | | | 62. **Signed by MD | | | | | 63. Signed by Clt (if clt not available efforts to obtain or meet with clt must be documented) | | | | | 64. Coordination of Care | | | | | SERVICE ATTENDANCE | Yes | No | n/a | | --- | --- | --- | --- | | 65. Date each session attended | | | | | 66. Type of session (ind/grp) | | | | | PROGRESS NOTES | | | | | 67. Each face to face note documents progress related to clt plan | | | | | 68. 1< goals | | | | | 69. New Issues or Problems that affect their recovery | | | | | 70. Type of Support Provided | | | | | 71. Min. 20 hrs/wk of indiv, grp, or structured activity | | | | | 72. Exceptions to tx freq noted | | | | | PERINATAL CERTIFICATION | | | | | Attends education/training on: | | | | | 73. Child development | | | | | 74. Parenting skills | | | | | 75. Impact of SA while preg | | | | | 76. Impact of SA while Br. Feed | | | | | 77. Environ impact of SA on child | | | | | 78. HIV Educ and access to Test | | | | | 79. TB and access to testing | | | | | 80. Transport/Access to medical, dental, Social

FAQs

What treatment documentation areas are included in the DMC audit checklist?

The checklist includes informed materials and participant rights, demographics and admission information, discharge summary criteria, client assessment items, and the individualized client plan or recovery plan with required signatures and coordination details.

What admission and medical necessity items are audited?

Admission audit items include date and type of admission, referral source, health questionnaire, and documentation requirements such as medical necessity with required MD signature and perinatal proof of pregnancy, along with dates tied to birth or term of pregnancy and postpartum treatment.

What does the audit tool review for ongoing progress and services?

It audits service attendance per session, session type (individual or group), and progress notes showing face-to-face updates related to the client plan, including goals, new issues affecting recovery, support provided, and minimum weekly activity hours and noted exceptions.

Sep 2, 2026

Upload by Bill Black