The Joint Commission's standards for behavioral health care—specifically regarding the Record of Care, Treatment, and Services (RC)—are designed to ensure that documentation supports safe, effective, and high-quality care.

• Behavioral/emotional and physical health screenings

• Suicide risk assessments

• Screening for abuse, neglect, trauma, or exploitation

• Measurable objectives and goals

• Individualized plans based on assessment data

• Regular updates and reviews

• Timely entries that reflect interventions, client responses, and progress

• Authenticated by appropriate staff

• Referrals, follow-up care, and medication instructions

• Documentation of transition or transfer of care

• Routine chart audits (e.g., tracers) to ensure completeness and accuracy

• Common deficiencies include vague treatment goals or missing signatures