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Self-Auditing Your Charts

Module 15: Quality Assurance and Outcome Measurement · Lesson 1 of 3

12 min Back to module

Story opener

Thursday, 4:40 p.m. A participant is sitting across from you, your supervisor wants three notes before you leave, and the answer you need is not in any binder on the shelf. This lesson is the part of the job nobody handed you in orientation.

Learning objectives

  • Be able to two random charts monthly
  • Be able to track and graph your own error rate

Lesson

Audit yourself monthly and nothing surprises you.

Pull two charts at random each month and check: authorization current, plan signed and reviewed on time, objectives measurable, notes tied to objectives, time supported by content, signatures complete.

Track your own error rate over time. Improvement you can show is a promotion argument.

Maryland guidance & authority labels

Every statement below is labeled so you know what is binding regulation, what is only proposed, what is professional guidance, and what is our house standard.

  • Internal best practice

    Run a five-chart self-audit monthly and track your personal error rate over time. Bring the trend to supervision.

  • COMAR — current

    Agencies must maintain a quality assurance process; individual chart integrity is the unit that process measures.

Common mistakes

  • Describing what you did without describing what the participant did.

    Do this instead — Record the intervention and the participant's observable response to it.

  • Treating regulation as a filing chore separate from practice.

    Do this instead — Let the required elements shape the session itself, so documentation writes itself.

Practical examples

Practical example

Instead of 'met with participant to discuss goals,' write: 'Reviewed the transportation objective; participant identified the #22 route unassisted and named one back-up plan. Verbal prompt needed once. Next session: practice the transfer at Mondawmin.'

Key takeaways

  • Two random charts monthly
  • Track and graph your own error rate

Reflection prompts

  1. 1Which part of this lesson describes something you are already doing differently in practice?
  2. 2What would an auditor see in your last five notes that contradicts this standard?

Bring your answers to supervision — the case-study workspace in this module saves written notes to your account.

Knowledge check

4 questions drawn from a bank of 7 · 75% to pass · instant feedback on every answer

1. How should you treat this statement? "Agencies must maintain a quality assurance process; individual chart integrity is the unit that process measures."

2. Which additional point does "Self-Auditing Your Charts" emphasize?

3. How should you treat this statement? "Run a five-chart self-audit monthly and track your personal error rate over time. Bring the trend to supervision."

4. Which is an outcome measure rather than an effort measure?