1Institution includes the following: hospital, jail, assisted living facilities, high supervision group homes, and other more restrictive settings. For sake of calculations, continue to treat those marked and as both community contacts (not office). = specialty practice occurs more than one time in 4-week period. 2Systematically provided “community” “institution” Team Name: _________________________ Reviewer Name: _________________________ Selected 4-Week Period for Review:___________________ Contact Location Team member/ Briefly note content and quality of contact. Do not include contact attempts or contacts with collaterals in final tally. C = Role Refer to CP1, CP3, and CP4 item guidelines to determine when to exclude a contact due to its questionable purpose and/or whether to (min.) Community collapse with another contact made on the same day. (OS2) I = Institution (CP3) O = Office (CP1) Team Leader Notes (total count; CT2) Co-Occurring Disorder Specialist (count; Employment Specialist Notes (count; ST4) Peer Specialist Notes (count; ST7) ST1) All notes (count): All notes (count): All notes (count): All (count): Specialist-related notes (count) Specialist-related notes (count): Specialist-related notes (count):
1Institution includes the following: hospital, jail, assisted living facilities, high supervision group homes, and other more restrictive settings. For sake of calculations, continue to treat those marked “community” and “institution” as both community contacts (not office). 2Systematically provided = specialty practice occurs more than one time in 4-week period. Team Name: _________________________ Reviewer Name: _________________________ Selected 4-Week Period for Review:___________________ Contact Location C = Community I = Institution O = Office (CP1) Team member/ Role (OS2) (min.) (CP3) Briefly note content and quality of contact. Do not include contact attempts or contacts with collaterals in final tally. Refer to CP1, CP3, and CP4 item guidelines to determine when to exclude a contact due to its questionable purpose and/or whether to collapse with another contact made on the same day. Team Leader Notes (total count; CT2) All notes (count): Co-Occurring Disorder Specialist (count; ST1) All (count): Specialist-related notes (count): Employment Specialist Notes (count; ST4) All notes (count): Specialist-related notes (count) Peer Specialist Notes (count; ST7) All notes (count): Specialist-related notes (count):
CHART-REVIEW-LOG-I_TMACT-1.0rev3.docx