The questions below are based on the C&P mental health examination clinical quality review tool. Items would be checked as excellent, good, average, needs improvement, or not applicable for role in this encounter. Any average or below average findings would be explained in a comments section on the form.

  1. For each diagnosed mental disorder, is there sufficient data provided to support that DSM-5 diagnostic criteria are fully met (all symptoms meet clinical threshold; symptoms are not better explained by other conditions; for PTSD exams, symptoms marked in Criteria B-E are clearly linked to traumatic exposure)? If no mental disorder was diagnosed, is there sufficient data to support the lack of a diagnosis?
  2. Does the report address any contradictions, discrepancies, or inconsistencies in the subjective/objective data, to include addressing the endorsement of exceptionally uncommon symptoms?
  3. If psychological testing was administered, was it utilized, interpreted, and documented properly?
  4. Does the body of the report support the Occupational and Social Impairment level that was endorsed on the documentation protocol?
  5. Does the body of the report support the items endorsed on the Symptoms/Other Symptoms section of the documentation protocol?
  6. Were Behavioral Observations documented and sufficient?
  7. In the Competency section of the documentation protocol, if endorsed as financially Incompetent, was this supported and explained?
  8. Does the report (documentation protocol) sufficiently address all required mental health specific elements from the 2507 exam request (to include, if applicable: claimed condition(s); medical opinion(s); functional impairment, IU, or both; and tabbed or identified records)?
  9. If the report indicates an urgent clinical need, is there documentation of a clinical response that is in accordance with applicable legal and ethical requirements and proportional to the circumstances (initiating a duty to warn and/or protect if applicable; providing reasonable assistance in securing follow-up care if warranted)?