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Office of Mental Health

New York State Office of Mental Health
Bureau of Inspection and Certification
Draft Tracer Flowing Questions

  1. Intake/Initial contact
    1. What is the referral source (self, hospital)
    2. When was the referral made
    3. Who did the intake person speak with (individual or referral source)
    4. When was the first contact with the person if they didn't self refer
    5. What key information was shared/requested – did intake staff ask sufficient questions to determine if referent should be considered high risk and prioritize for services
    6. Were arrangements made for language needs to be met
    7. What was the referring entity's experience with the referral and intake process
    8. What was the individual's and/or family's experience with the referral and intake process
      1. Were they made to feel welcomed
      2. Was there a sense that they could be helped and were cared about
      3. Was the initial clinical appointment provided within a reasonable period of time based on the individual's level of risk/need
    9. Was the first appointment with the psychiatrist provided within a reasonable period of time commensurate with the level of risk/need
  2. Evaluation
    1. Is there a timely comprehensive evaluation
    2. Is there a thorough exploration of current concerns, goals and symptoms
    3. Is there a review of mental health history including past successes and difficulties, and preferences, trauma history
    4. Is there a thorough identification of the client's social circumstances, culture, peer/community support, support network, and ongoing life-stressors
    5. Is there an initial risk assessment, including risk to self and others
    6. Does it include medical history and treatments
    7. Is input solicited from family, significant other(s) and other providers
  3. Treatment Plan
    1. Are the salient results of information obtained from the assessments & evaluations translated into a comprehensive treatment plan
    2. Is the frequency and intensity of services planned commensurate with the level of risk/need
    3. Are all key issues addressed or deferred with a rationale
    4. Is it consumer driven/person centered and recovery oriented with a focus on work/education, and culturally relevant
    5. Is there a safety/crisis plan in place and does the individual know who to contact in the event of a crisis or emergency
  4. Ongoing Care
    1. Was the treatment plan delivered as prescribed (Did the consumer/recipient have input into treatment plan?
    2. Is the treatment plan working, and if not, are changes being made
    3. Has the treatment plan been updated in accordance to recipient's progress
    4. Is there communication with other providers including the primary care physician
    5. Is there a coordination of the treatment approach with the recipient and other providers
    6. Are natural supports and peer support resources used
    7. Is medication education being provided
    8. Are appropriate referrals being made e.g. case management
    9. If indicated, is a new risk assessment completed
    10. If stressors are noted in progress notes is there evidence that the plan is reviewed, supervisor was consulted or referrals made for appropriate response
      1. Loss: job, family member/ sig. other death, relationship, housing
      2. Arrest or violent act
      3. Health issue/challenge
      4. Change in medication
    11. If individual has not been engaged in treatment, is there evidence of outreach
      1. Calls and letters
      2. To other providers
      3. To family members
      4. Home visits
      5. Especially if there is a high risk of violence
    12. If the individual has been discharged
      1. has information been shared with new provider (if applicable)
      2. has the clinic followed up with individual post discharge

Methods for obtaining information could include:

Note: Other question sets may be used for individuals with co-occurring disorders, serious physical health issues, and children.