Peer Review - Chart Audit Form (revised)

Purpose summary: This peer review evaluates the quality, safety, and appropriateness of psychiatric medication management provided to the individual served. The review assesses whether diagnoses are supported by clinical evidence; medications are appropriate for the individual's symptoms, needs, and preferences; contraindications, adverse effects, and medication interactions are identified and addressed; required monitoring protocols are completed; and clinical decision-making is documented in accordance with accepted standards of psychiatric practice. Special attention should be given to the use of multiple medications, ensuring that treatment rationale, benefits, risks, and monitoring plans are clearly documented. The review should determine whether care is consistent with evidence-based guidelines and supports positive clinical outcomes.

Peer Review - Chart Audit Form

Peer reviews should assess the appropriateness of each medication, as determined by the needs and preferences of the person, determine whether contraindications and side effects were identified and addressed, necessary monitoring protocols were implemented, and if there was simultaneous use of multiple medications including polypharmacy and co-pharmacy.
Individual's Name (Patient):(Required)
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Practioner's Name:(Required)
Supervising MD's Name:(Required)

Audit

Indicate the quality of care received by the individual (patient) in the areas below based upon your review of the clinical record.
1_a. Diagnosis substantiated by recorded data.
The psychiatric diagnosis is supported by documented clinical assessment, history, symptoms, and relevant diagnostic data (DSM-5).
2_a. Practioner orders reflect dosage adjustments and combinations consistent with patient safety and accepted evidence-based guidelines.
3_b. Evidence of practitioner's involvement in multidisciplinary treatment planning process.
4_a. Treatment begins with appropriate monotherapy when clinically indicated, or documentation clearly supports the rationale, risks, benefits, and monitoring plan for combination therapy or polypharmacy.
5_a. Progress notes accurately reflect clinical observations, symptom status, treatment response, functional outcomes, and ongoing assessment.
6_a. Medication effectiveness, side effects, adherence, and patient-reported outcomes are routinely assessed and documented. Required laboratory or clinical monitoring is completed when indicated.
7_a. Documentation clearly supports clinical decisions, including medication initiation, dose changes, discontinuation, treatment transitions, referrals, and discharge planning.
8_a. Documentation is complete, legible, timely, and professionally maintained.
9_a. Informed consent for medication completed with accordance with policy.
10_a. The review identified and evaluated potential medication interactions, contraindications, duplicate therapies, and other medication-related safety concerns.
11. Overall quality assessment. Based on the clinical information available in the note: 
Select one.
Reviewer Attestation: I certify that I have reviewed the clinical record and completed this evaluation based on the documentation available and accepted standards of practice.
Clear Signature
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