CQRT Checklist- Post CalAIM
Client Name:	Client PSP#:

Review Components

Informing Materials/Consents	Yes	No	N/A
1.Informing Materials page is signed/initialed and on time.	☐	☐	☐
2. Informed consent for medication(s) is present for each prescribed medication (when applicable) and includes signature of the person providing the service, their professional degree, licensure or job title, relevant identification number (e.g. NPI) and signature date. Also signed by beneficiary, and if not signed, reason why not.	☐	☐	☐
Assessment & Medical Necessity
3. Required assessment (including all components) is present and signed by staff with credentials to do so. If not present, reason for delay is noted.	☐	☐	☐
4. The Client's physical limitations, cultural and communication needs, or lack thereof, are noted.	☐	☐	☐
5. Documentation of coordination of care is present, anywhere in the chart, as clinically appropriate.	☐	☐	☐
6. CANS/ANSA is finalized and signed on time (with all sections completed) by staff with credentials to do so.	☐	☐	☐
7. PSC35 is present or documentation of parent refusal/lack of response is in chart.	☐	☐	☐
8. MH diagnosis or suspected diagnosis (includes Z codes) is present. If suspected or Z code is used, notes indicate efforts to clarify the diagnosis.	☐	☐	☐
9. Meets Access Criteria and/or Medical Necessity.	☐	☐	☐
10. If risk (DTS/DTO/Other high risk) occurred in the past 90 days, there is a comprehensive risk assessment and safety plan.	☐	☐	☐
Problem List
11. A Problem List is present and supported by the documentation in the chart.	☐	☐	☐
12. The progress note was signed (or electronic equivalent) by the person(s) providing the service and the service provided was within the scope of practice of the person delivering the service.	☐	☐	☐
13. Progress notes describe how interventions address beneficiary’s mental health needs or Social Determinants of Health and planned action steps. If non-reimbursable services were provided, the note clarifies that the time was not claimed.	☐	☐	☐
14. Notes for services involving one (1) or more providers, include: a) Total number of providers and their specific involvement in delivering the service, b) Time involved in delivering the service for each provider (includes travel and documentation); c) Total number of beneficiaries participating in the service.	☐	☐	☐
15. For Case Management services, there is a care plan present in a progress note.	☐	☐	☐
Chart Status
☐Approved No major changes or coaching needed ☐Approved with Coaching No major changes needed but reviewer sees opportunity for growth and provides coaching ☐Not approved Changes must be made and the chart needs to be reviewed again during the next CQRT
Comments (Required if clarification is needed)
Reviewer Name:	Date:
Reviewer Signature:
CQRT Chair Name:	Date:
CQRT Chair Signature: