Effective Date: 
Sat, 01/01/2005
Tue, 02/25/2014
Tue, 02/25/2014

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 Form


Clinician: _______________________

Dates of Service __________________

Date of Review: __________________

The selection of this client is appropriate given the scope of counseling services

YES         NO         N/A

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 for the findings in the history.

YES         NO         N/A

Treatment is consistent with the working diagnoses or diagnostic impressions

                         YES        NO         N/A

There is evidence of attention to the client’s developmental needs.

YES         NO         N/A

Consultation and referrals are appropriate and timely

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

YES         NO         N/A

Intake notes, session notes, and test interpretations, if applicable, are included and were completed in a timely manner.              

YES         NO         N/A

Are the notes completed for each visit?

YES         NO        

Are all counseling visit notes completed after contact with student consistent with CAPS policies for completion of clinical documentaiton?

Intakes                                yes       no

Follow up notes                    yes       no

Crisis assessment                 yes       no

Suggestion to improve the quality of treatment rendered: (i.e., even if treatment is appropriate, are there ways to improve upon it?)




1.         Treatment appropriate: No follow-up necessary.

2.         Review by Management Team recommended.



Peer Reviewer