Compliance Resources

Compliance Checklist

A comprehensive checklist outlining the essential elements for compliant clinical documentation, including intake assessments, treatment plans, progress notes, and discharge summaries. Helps ensure timely signatures and adherence to clinical and legal standards.

Cyber Hygiene Checklist

A practical guide with cybersecurity best practices for protecting client privacy in remote and personal device work settings. Covers topics like secure passwords, device safety, minimizing PHI exposure, and AI/data protection.

Intake Template – Bulleted

An intake assessment template in bulletpoint format, covering presenting problems, clinical observations, risk assessments, psychosocial history, and treatment planning. Designed to streamline documentation while maintaining compliance with HIPAA.

Intake Template – Narrative

A narrative-style intake assessment template for documenting client history, mental status, risk factors, and treatment goals in paragraph form. Offers a flexible, client-centered approach while ensuring compliance and thoroughness.

Sample Chart Audit Form

A detailed audit tool for reviewing clinical charts against compliance standards, assessing documentation accuracy in intakes, treatment plans, progress notes, and discharge summaries. Identifies discrepancies and guides quality improvement.

Timely Documentation Tips

A checklist and tips sheet for clinicians to maintain timely documentation practices. Provides strategies like concurrent note-taking, task scheduling, and distraction reduction to ensure documentation is completed within required timeframes.