Effective Date: 
Sat, 01/01/2005
Mon, 05/07/2018
Wed, 01/31/2018

Peer Review is an integral component of the Clinical Quality Management and Improvement program, and shall be conducted on a regular and ongoing basis by CAPS staff.

Purpose of Peer Review:

  • Monitoring of indicators of clinical quality and conformity with UCSC CAPS Service and community standards of care.
  • Identifying opportunities for improvement in clinical care and providing feedback and educational opportunity for staff for clinical service provision
  • Providing information to the Director as one component of the staff evaluation process.

1.      Twice yearly, during the academic term, five cases per clinician (psychologist, therapist, case manager, intern, postdoc) will be randomly distributed to the counseling staff for peer review.  Three of the cases will include documentation from intake appointments (2 routine and 1 priority intake) and follow up counseling visits, and two will include crisis services evaluations.  The counseling records will include those records starting from the initial contact with the student in the past two quarters under review.

2.      The reviewers will use a peer review form (see below) to evaluate whether the counseling service met CAPS Counseling Services and community standards of care.

3.      Counseling records will be reviewed in the electronic health record.

4.       Clinical documentation recommended by peer reviewers for further review will be reviewed a second time by a member of the CAPS management team.  If a second review is required for the records of a CAPS management staff member, another management team staff member will review the records.

4.      Counseling staff will receive a summary sheet detailing results of the peer review.  This summary will also be provided to the CAPS Director and supervisor of the staff member.  If the counseling staff member disagrees with the peer review results, they may respond directly or in writing to the CAPS Director, who will provide a written reply.

5.      If necessary, training will be provided to the counseling staff on general themes and issues that arise from the peer review process.

6.      Results are shared with the CAPS Clinical Quality Committee and the SHS Quality Management Committee.

Peer Review Fall 2017 – Counseling Senior Staff

Staff Reviewer            _________ _____________                  Student ID number: ___________

Staff Reviewed            ______________________

The history is adequate based on the chief complaint and other entries in the chart.

  YES                           NO                               N/A

The diagnoses or diagnostic impressions are appropriate.

  YES                           NO                               N/A

Treatment goals are appropriate for the presenting concern and the brief therapy model

YES                             NO                              N/A

Timely and appropriate consultation with medical services is evidenced in the medical record (if indicated).

YES                             NO                              N/A

Consultation with internal CAPS providers is evidenced in the medical record (if indicated).

YES                             NO                              N/A

Appropriate follow-up is provided, with consideration to risk level

  YES                           NO                              N/A

Adjunct services are given adequate consideration.

YES                             NO                              N/A

The PnC treatment plan flowsheet is being utilized consistently and appropriately

YES                             NO                              N/A

Clinical Comments entry was documented (if necessary)

YES                             NO                               N/A

The record contains all necessary forms and they are scanned into the electronic health record

YES                             NO                               N/A

Clinical documentation is completed for each visit.

  YES                           NO   

All clinical documentation - intake notes, session notes, crisis assessments, and follow-up notes are included and were completed consistent with CAPS policies for completion of clinical documentation.                                                                           

Yes      No

Initial Assessment/First Follow ups                   3 working days

Follow up notes                                                2 working days

Crisis Notes                                                      1 working day

5150’s                                                             by end of day


Treatment appropriate: No follow-up necessary.        

Review by Management Team recommended.