Meeting Clinical and Regulatory Standards


A customer was struggling with a way to standardize and document the clinical practices of her program and program staff. The original policies and practice regarding clinical documentation had been changed, misinterpreted and not consistently followed over time. This created variation in frequency and quality of case documentation, chaos and difficulty when trying to systematically review cases for utilization management, quality assurance activities and supervision, as well as frustration and confusion among staff.

The customer was hoping we could assist her with creating a standardized case documentation process that adhered to all regulatory requirements and supported her staff with user friendly case documentation templates. By standardizing all case documentation requirements, the supervisor could also begin to monitor, manage and appropriately supervise her staff using consistent data across all caseloads.


CCNY combined the required regulatory requirements (minimum documentation standards) with stakeholder (supervisor and her staff) feedback to deliver a comprehensive clinical document to supervise staff practice as well as monitor clinical progress.
CCNY supported the customer in training her staff in the revised documentation process. Included in the training package were hard copies of the templates, curriculum for training new staff when there is turnover in the future, and articles demonstrating impact of standardized documentation on employee time management and overall effectiveness.
Tools used: process mapping, policy analysis, stakeholder focus groups, training


By providing staff with clear standards of practice and easy to use templates, staff documentation time dropped significantly thus allowing for more time spent in billable client service hours and an increase in program revenue.

Our customer was able to immediately utilize the templates to supervise her employee’s practice, increase accountability, and clarify/address implementation issues.
Our customer reports improved documentation of practice, consistency in documentation across cases and across employees, and compliance with new policies.
Employees reported that training was comprehensive, easy to understand and the presenter was personable, precise, and knowledgeable.