# Treatment Plan Quality Assurance Checklist

## Overview

Use this checklist to ensure treatment plans meet professional standards for completeness, quality, safety, and regulatory compliance. Review each section before finalizing the plan.

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## Section 1: Completeness - Required Components

### ☐ Patient Information
- [ ] Patient identifier (de-identified if sharing)
- [ ] Age range (not exact date of birth)
- [ ] Sex and relevant demographics
- [ ] Date of plan creation
- [ ] Provider name and credentials
- [ ] Facility/practice name
- [ ] HIPAA de-identification notice included

### ☐ Diagnosis and Assessment
- [ ] Primary diagnosis clearly stated
- [ ] ICD-10 code(s) included
- [ ] Secondary diagnoses and comorbidities listed
- [ ] Disease severity/staging documented
- [ ] Baseline functional status assessed
- [ ] Risk stratification performed (if applicable)

### ☐ Treatment Goals
- [ ] Short-term goals present (1-3 months)
- [ ] Long-term goals present (6-12 months)
- [ ] Goals meet SMART criteria (see Section 2)
- [ ] Patient-centered goals included
- [ ] Goals are prioritized or organized

### ☐ Interventions
- [ ] Pharmacological interventions specified
- [ ] Non-pharmacological interventions included
- [ ] Procedural interventions or referrals noted
- [ ] Each intervention has clear rationale
- [ ] Evidence-based or guideline-concordant

### ☐ Timeline and Schedule
- [ ] Treatment phases with durations defined
- [ ] Appointment frequency specified
- [ ] Milestone assessments scheduled
- [ ] Expected total treatment duration stated

### ☐ Monitoring Parameters
- [ ] Clinical outcomes to track identified
- [ ] Baseline values documented
- [ ] Target values specified
- [ ] Monitoring frequency defined
- [ ] Assessment tools/scales named

### ☐ Expected Outcomes
- [ ] Primary outcome measures stated
- [ ] Success criteria defined
- [ ] Timeline for improvement indicated
- [ ] Criteria for treatment modification noted

### ☐ Follow-up Plan
- [ ] Next appointment scheduled
- [ ] Follow-up frequency specified
- [ ] Communication plan outlined
- [ ] Emergency contact procedures included

### ☐ Patient Education
- [ ] Condition education documented
- [ ] Self-management skills training noted
- [ ] Warning signs communicated
- [ ] Resources and support listed

### ☐ Risk Mitigation and Safety
- [ ] Potential adverse effects identified
- [ ] Safety monitoring plan included
- [ ] Emergency procedures outlined
- [ ] Complication prevention addressed

### ☐ Signature and Date
- [ ] Provider signature line
- [ ] Provider name and credentials
- [ ] Date of plan
- [ ] Patient acknowledgment (if applicable)

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## Section 2: SMART Goals Quality

For each treatment goal, verify it meets SMART criteria:

### ☐ Specific
- [ ] Goal clearly defines what will be accomplished
- [ ] No vague language (e.g., "improve", "better")
- [ ] Specific outcome stated

**Example**: "Reduce HbA1c from 8.5% to <7%" ✓  
**Not**: "Improve diabetes control" ✗

### ☐ Measurable
- [ ] Quantifiable metric or observable criterion included
- [ ] Baseline value documented
- [ ] Target value specified

**Example**: "Walk 300 feet with walker independently" ✓  
**Not**: "Walk further" ✗

### ☐ Achievable
- [ ] Realistic given patient's condition and capabilities
- [ ] Resources available to support goal
- [ ] Timeframe is reasonable
- [ ] Treatment efficacy supports goal

**Example**: "Reduce pain from 7/10 to 4/10 in 6 weeks" ✓  
**Not**: "Eliminate all pain in 1 week" ✗

### ☐ Relevant
- [ ] Aligned with patient values and priorities
- [ ] Clinically meaningful
- [ ] Addresses patient's functional limitations
- [ ] Integrated with overall treatment objectives

**Example**: "Return to work with modifications within 3 months" ✓  
**Not**: "Lab value improvement" (if patient doesn't care about it) ✗

### ☐ Time-bound
- [ ] Specific deadline or timeframe stated
- [ ] Reassessment interval defined
- [ ] Action frequency specified (if applicable)

**Example**: "Within 8 weeks" or "By month 3" ✓  
**Not**: "Eventually" or "Soon" ✗

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## Section 3: Clinical Quality

### ☐ Evidence-Based Practice
- [ ] Interventions based on current evidence
- [ ] Clinical practice guidelines followed
- [ ] Guideline deviations explained and justified
- [ ] Literature or evidence cited (if formal plan)

### ☐ Medication Documentation (if applicable)
- [ ] Generic drug names used
- [ ] Specific dose, route, frequency documented
- [ ] Indication/rationale provided for each medication
- [ ] Adverse effects to monitor noted
- [ ] Drug interactions considered
- [ ] Titration plan included if applicable

### ☐ Assessment Tools
- [ ] Validated assessment tools used when available
- [ ] Tools appropriate for condition (PHQ-9, FIM, Berg, etc.)
- [ ] Baseline scores documented
- [ ] Target scores specified
- [ ] Reassessment schedule defined

### ☐ Multidisciplinary Coordination (if applicable)
- [ ] Roles of team members defined
- [ ] Communication plan among providers specified
- [ ] Care transitions addressed
- [ ] Specialist recommendations integrated

### ☐ Preventive Care Integration
- [ ] Age-appropriate screening included
- [ ] Vaccination schedule noted
- [ ] Lifestyle counseling documented
- [ ] Health maintenance addressed

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## Section 4: Patient-Centered Care

### ☐ Shared Decision-Making
- [ ] Patient preferences documented
- [ ] Treatment options discussed
- [ ] Risks and benefits explained
- [ ] Patient values incorporated into goals
- [ ] Alternative treatments considered

### ☐ Health Literacy
- [ ] Language appropriate for patient understanding
- [ ] Medical jargon explained or avoided
- [ ] Teach-back method used or planned
- [ ] Written materials at appropriate reading level

### ☐ Cultural Competence
- [ ] Cultural beliefs and practices considered
- [ ] Language barriers addressed (interpreter if needed)
- [ ] Cultural adaptations made when appropriate
- [ ] Religious/spiritual preferences respected

### ☐ Social Determinants of Health
- [ ] Social needs screened (food, housing, transportation)
- [ ] Barriers to care identified
- [ ] Community resources provided
- [ ] Financial concerns addressed (medication costs, etc.)

### ☐ Patient Engagement
- [ ] Patient actively involved in goal-setting
- [ ] Self-management support provided
- [ ] Patient education tailored to individual
- [ ] Follow-up preferences considered

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## Section 5: Safety and Risk Management

### ☐ Medication Safety
- [ ] Allergy history documented
- [ ] Polypharmacy reviewed (deprescribing considered)
- [ ] High-risk medications monitored appropriately
- [ ] Drug-drug interactions checked
- [ ] Renal/hepatic dosing adjustments made if needed

### ☐ Fall Prevention (if relevant)
- [ ] Fall risk assessed
- [ ] Fall prevention strategies included
- [ ] Environmental modifications recommended
- [ ] Assistive devices prescribed

### ☐ Infection Prevention (if relevant)
- [ ] Immunizations up to date
- [ ] Prophylactic antibiotics if indicated
- [ ] Infection signs and symptoms patient education

### ☐ Emergency Preparedness
- [ ] Emergency warning signs clearly listed
- [ ] When to call 911 specified
- [ ] When to call provider defined
- [ ] Emergency contact numbers provided

### ☐ Suicide/Violence Risk (mental health plans)
- [ ] Risk assessment documented
- [ ] Safety plan created if ideation present
- [ ] Means restriction addressed
- [ ] Crisis resources provided (988 lifeline)
- [ ] Follow-up frequency appropriate for risk level

### ☐ Opioid Safety (pain management plans)
- [ ] Opioid risk assessment completed (ORT, SOAPP)
- [ ] Informed consent discussion documented
- [ ] Treatment agreement signed
- [ ] PDMP checked
- [ ] Naloxone co-prescribed
- [ ] UDS plan included

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## Section 6: Regulatory Compliance

### ☐ HIPAA Compliance
- [ ] Protected health information (PHI) safeguarded
- [ ] De-identification per Safe Harbor method (if sharing)
- [ ] All 18 HIPAA identifiers removed (if de-identified)
- [ ] Minimum necessary principle followed

### ☐ Informed Consent
- [ ] Consent discussion documented
- [ ] Patient understanding verified
- [ ] Risks and benefits explained
- [ ] Alternative treatments discussed
- [ ] Patient agreement documented

### ☐ Medical Necessity
- [ ] Treatment medically necessary for diagnosis
- [ ] Interventions appropriate for severity
- [ ] Evidence supports treatment choices
- [ ] Frequency and duration justified

### ☐ Billing and Coding
- [ ] ICD-10 diagnosis codes included
- [ ] CPT procedure codes (if procedures planned)
- [ ] Documentation supports billing level
- [ ] Medical necessity for services demonstrated

### ☐ Quality Measure Support
- [ ] Elements support quality reporting (HEDIS, MIPS)
- [ ] Chronic disease management protocols followed
- [ ] Preventive care documented
- [ ] Patient safety indicators addressed

### ☐ Specialty-Specific Regulations
- [ ] 42 CFR Part 2 compliance (if substance use disorder treatment)
- [ ] CDC opioid guidelines followed (if opioid prescription)
- [ ] Joint Commission standards met (if applicable)
- [ ] State-specific requirements addressed

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## Section 7: Documentation Standards

### ☐ Clarity and Precision
- [ ] Professional medical terminology used appropriately
- [ ] Abbreviations defined on first use
- [ ] No ambiguous language
- [ ] Specific rather than vague descriptions

### ☐ Accuracy
- [ ] Factually correct information
- [ ] Current evidence-based recommendations
- [ ] Correct medication dosing and frequencies
- [ ] Proper ICD-10 and CPT coding

### ☐ Organization
- [ ] Logical flow and structure
- [ ] Consistent formatting
- [ ] Easy to locate key information
- [ ] Headings and sections clearly labeled

### ☐ Legibility (if handwritten or hybrid)
- [ ] Handwriting legible
- [ ] No unclear abbreviations
- [ ] Typed portions clear
- [ ] Signatures legible with printed name

### ☐ Authentication
- [ ] Provider name clearly stated
- [ ] Credentials included
- [ ] Date of plan present
- [ ] Signature obtained (electronic or handwritten)

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## Section 8: Special Considerations by Plan Type

### For General Medical Plans:
- [ ] Chronic disease management protocols followed
- [ ] Guideline-based targets used (HbA1c, BP, lipids)
- [ ] Medication regimen optimized
- [ ] Comorbidities addressed
- [ ] Preventive care integrated

### For Rehabilitation Plans:
- [ ] Functional assessments with validated tools (FIM, Berg)
- [ ] Impairment, activity, and participation goals included
- [ ] Therapy frequency and duration specified
- [ ] Home exercise program documented
- [ ] DME and environmental modifications listed
- [ ] Discharge criteria defined

### For Mental Health Plans:
- [ ] DSM-5 diagnostic criteria met
- [ ] Symptom severity assessed (PHQ-9, GAD-7, etc.)
- [ ] Suicide/violence risk assessed
- [ ] Safety plan created (if indicated)
- [ ] Evidence-based psychotherapy specified
- [ ] Medication trials and responses documented
- [ ] Functional and recovery-oriented goals included

### For Chronic Disease Management Plans:
- [ ] All active conditions prioritized
- [ ] Medication synergies identified
- [ ] Polypharmacy addressed
- [ ] Care coordination plan clear
- [ ] Registry/population health integration noted
- [ ] Transition management included

### For Perioperative Plans:
- [ ] Preoperative risk assessment (RCRI, ASA, Caprini)
- [ ] Medical optimization documented
- [ ] ERAS elements included (if applicable)
- [ ] Postoperative milestones defined
- [ ] Discharge criteria specified
- [ ] VTE prophylaxis plan included

### For Pain Management Plans:
- [ ] Comprehensive pain assessment (location, quality, intensity, impact)
- [ ] Pain type classified (nociceptive, neuropathic, nociplastic)
- [ ] Multimodal analgesia approach
- [ ] Opioid risk assessment (if opioids considered)
- [ ] Functional goals emphasized (not just pain scores)
- [ ] Psychological screening and intervention included
- [ ] CDC opioid guidelines followed (if prescribing)

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## Section 9: Final Review

### ☐ Proofreading
- [ ] Spelling and grammar checked
- [ ] No typos or errors
- [ ] Consistent terminology throughout
- [ ] Patient name correct throughout (if not de-identified)

### ☐ Completeness Verification
- [ ] All placeholder text replaced with patient-specific information
- [ ] All bracketed [fields] customized
- [ ] No "TBD" or "to be completed" items remaining
- [ ] All required sections complete

### ☐ Quality Assurance
- [ ] Plan reviewed by provider
- [ ] Peer review completed (if applicable)
- [ ] Compliance verification done
- [ ] Automated checks run (if available scripts used)

### ☐ Patient Review Preparation
- [ ] Patient-friendly summary prepared (if needed)
- [ ] Patient education materials gathered
- [ ] Consent forms ready for signature
- [ ] Questions anticipated and prepared to address

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## Scoring and Interpretation

**Total Items**: ~150 (varies by plan type)

### Scoring:
- Count number of checked items
- Calculate percentage: (Checked / Total) × 100

### Interpretation:
- **95-100%**: Excellent - Plan meets highest quality standards
- **85-94%**: Good - Plan is high quality with minor gaps
- **70-84%**: Acceptable - Plan is adequate but has areas needing improvement
- **<70%**: Needs Improvement - Significant gaps in quality or compliance

### Critical Items (Must Have):
The following items are critical and must be present:
- ✓ Patient identifier and de-identification notice
- ✓ Primary diagnosis with ICD-10 code
- ✓ At least 3 SMART goals
- ✓ Interventions with rationales
- ✓ Monitoring plan
- ✓ Follow-up plan
- ✓ Patient education
- ✓ Safety/risk mitigation
- ✓ Emergency procedures
- ✓ Provider signature

If any critical item is missing, plan should not be finalized until corrected.

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## Usage Instructions

1. **Review each section** systematically
2. **Check boxes** as criteria are met
3. **Note deficiencies** for correction
4. **Calculate score** to assess overall quality
5. **Address gaps** before finalizing
6. **Document review** with reviewer name and date

**Reviewer**: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Date Reviewed**: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Score**: \_\_\_\_\_% (\_\_\_\_ items checked / \_\_\_\_ total items)

**Status**:
- [ ] Approved for use
- [ ] Approved with minor revisions
- [ ] Requires significant revision
- [ ] Not approved

**Comments/Recommendations**:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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**Document Version**: 1.0  
**Last Updated**: January 2025  
**Next Review**: Annually or with guideline updates

