PROCEDURE FOR FILE AUDIT

1. Remove client files from the file cabinet where they are stored.
2. You will need to begin with a File Audit sheet, a sample copy is attached and can be
found in the procedure manual.
3. The following materials may, or may not, be necessary to complete your file audit:
a. Pen
b. Flag, or Post It Tabs
c. Post It Notes
d. Label Tabs
e. Therapy Appointment (for reference)
4. Begin with first file of alphabetical sequence by the clients last name.
5. In the first section of the File Audit sheet, under the column titled Initials for File, write
in clear print the client initials (First Initial. Last Initial.).
6. Under the column titled Tabs Present place a check mark () only if the file has all of
the following:
a. Complete first and last name of client labeled on the file tab (last name, first name)
b. A label in the top left corner of the front face of the folder clearly stating
i. The clients date of birth (DOB: 00/00/0000)
ii. The date of the clients initial appointment (First Seen/First Appt.: 00/00/0000)
c. A label in the top right corner of the front face of the folder clearly stating
i.
The date of the clients last appointment if inactive (Last Seen/ Last Appt.:
00/00/0000)
*If the client is still an active client, the top right corner of the file should still
be labeled with Last Seen/ Last Appt., but should be blank for the final
appointment date. (See step 10 for active/ inactive clients).
7. Under the column titled Intake Present, place a check mark () only if the file has all
of the following:
a. The General Intake Information Form
*If the file is missing any of the forms above, flag the file by placing a red post it tab
upright on the folder tab labeled with the clients name.
* Place a removable note (post it) on the inside face of the clients folder stating the
reason for the flag and what is needed for that file. If any documents between two
clients are shared and are only in one file, make note of this here as well.
8. Under the column titled Consent Signed, place a check mark () only if the file has
all of the following and there are initials/ signatures where appropriate:
a. Client Rights Form
b. HIPPA Notice of Privacy Practice
*If the file is missing any of the forms above, or appropriate signatures flag the file
by placing a red post it tab upright on the folder tab labeled with the clients name.
* Place a removable note (post it) on the inside face of the clients folder stating the
reason for the flag and what is needed for that file. If any documents between two
clients are shared and are only in one file, make note of this here as well.
9. Under the column titled Custody Papers Present, place a check mark () only if the file
has at least one of the following:
a. Child Custody Document

PROCEDURE FOR FILE AUDIT

b. Divorce Decree
c. Other appropriate legal documentation
*If the file does not have any of the following or is lacking the appropriate legal
documentation, flag the file by placing a red post it tab upright on the folder tab
labeled with the clients name.
* Place a removable note (post it) on the inside face of the clients folder stating the
reason for the flag and what is needed for that file. If any documents between two
clients are shared and are only in one file, make note of this here as well.
10. Under the column titled Active/ Inactive in Therapy Appointment, write active in the
space provided if the client is still an active client and inactive is the client is no longer
being seen. To check the status of a client:
a. Log into Therapy Appointment
b. Once logged in, type the last name of the client into the white search box located in
the top left corner of the screen just above the blue tabs, then click the blue tab
labeled old patients just below the search box
c. The clients first and last name should appear in a blue tab in the center of the screen
if the client is active. If the client is inactive, there will be a single grey tab in the
center of the screen prompting you to (include inactive patients). Click this grey tab
to reveal any inactive clientele.
*Inactive patients are in grey and Active patients are in blue.
*If a patient is active in therapy appointment but has not been seen in more than 4
months after being contacted, mark the client file as inactive (to be changed in
Therapy Appointment).
11. Under the column titled In-office Files or Closed Files, write In- office in the space
provided if the client is still an active client and Closed if the client is inactive.
12. Under the column titled Initials, the auditor should sign his/her initials at the end of the
row only if all of the following are true:
a. Client Initials are written in the first column for the client file
b. All tabs are present or have been placed and updated, as well as accounted for on the
File Audit sheet
c. The General Intake Information form is inside the client file and has been accounted
for on the File Audit sheet
d. The Client Rights form and HIPPA Notice of Privacy Practice form are initialed,
signed and present in the clients file as well as accounted for on the File Audit sheet
e. Appropriate legal documentation is present in the file and accounted for on the File
Audit sheet, if necessary
f. The client file has been marked as active or inactive on the file audit sheet
g. The client file has been marked as either in- office or closed on the File Audit sheet
13. Place the folder in one of two stacks according to client status:
a. Active- Place files back in alphabetical order by the clients last name to be returned
to office file cabinet
b. Inactive- Place files in alphabetical order by the clients last name to be placed in the
closed files cabinet located in the play room closet.

PROCEDURE FOR FILE AUDIT

14. Repeat steps 4-13 with remaining files until all files have been inspected and placed in
the appropriate location.