Sarah Johnson is the health information manager for the Columbus County Alcohol and Drug Treatment Center, a CARF accredited, publicly funded treatment facility. as a member of the quality improvement (QI) committee, Sarah has been reviewing client records, focusing on written clinical assessments and treatment plans. The OI committee is interested in evaluating how consistently the clinicians document appropriate treatment goals based on the information found in the clinical assessment. One of the records that Sarah reviewed is an outpatient record for Ann Wilson, a 24-year old female client enrolled in the center’s woman’s program. Based on the following summaries of Ms. Wilson’s clinical assessment and treatment plan, what specific feedback should Sarah give to the committee? Do the treatment goals and objectives relate to the person’s goals? are they written in measurable terms? Do they specify treatment interventions and their frequency?
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