Chart Audits

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How we can help you

Using Critical Thinking to create the patient plan of care.

The worst disservice a clinician can do their patient and employer is not to use critical thinking when developing, implementing, revising the patient's Plan of Care, see "Using "Critical Thinking" during clinical practice..."

CMS Quality Measurements Projects and the Goals

CMS is presently developing outcome core measures that are patient oriented and cross providers setting during the continuum of care.

CMS Proposed Rule of the Home Health QAPI Program

CMS propose regulations needs more work! Make home care organizations assign the QAPI Program responsibilities to a staff member who is free of conflict between the non-clinical and clinical departments in the home care organization.

Discipline Frequency and Duration Orders

Did you know that the Medicare week to write orders for treatments and/or frequency and duration varies from home health agency to home health agency? For more information see "Are you knew to the home…?”

Tips

Ready for CMS QAPI Program?

According to CMS in 2011 several nursing homes providers begun testing CMS QAPI Program, Quality Assurance (QA) and Performance Improvement (PI), Program which includes Five Elements...

OASIS Tip - M1600 Patients discharged with an UTI on discharge and PAEs Report

Are your Potentially Avoidable Events (PAEs) Report showing an increase in patients being discharged while having an UTI?

Falls

Patients falls are a marker of frailty, immobility...

Chart Audits for Home Health Care Agencies 

Performing chart audits consistently will provide you organization with data that supports compliance with regulations and standards of practice.
The results from this audit event can assist management to prioritize assignment of resources for education for clinicians and assist to identify processes that need to be revised as compliance with Face to Face. 

 

Non-Clinical Indicators

General

# Charts Audited

Yes

No

N/A

% of compliance

 

Intake Referral (verbal order) signed by RN

17

17

 

3

100%

 

Initial comprehensive functional evaluation/assessment was performed within 48 hours of Mod Order or "As of Date" on POC, unless otherwise stated.

17

17

 

3

100%

 

F2F form completed and signed by physician.

17

14

3

3

82%

 

Advanced Directives discussion documented on consent and SOC OASIS pg. 4

17

9

8

3

53%

POC (Initial)

# Charts Audited

Yes

No

N/A

% of compliance

 

Initial case conference sheet- (located behind OASIS) complete with appropriate care needs addressed

17

17

 

3

100%

 

Diagnoses appropriate for episode of care

17

15

2

3

88%

ROC Orders

# Charts Audited

Yes

No

N/A

% of compliance

 

ROC verbal physician orders include:

1

1

 

19

100%

 

Hospital dates

1

1

 

19

100%

 

All applicable disciplines X freq X duration

1

1

 

19

100%

 

Interventions/treatments

1

1

 

19

100%

 

New/changed medications

1

1

 

19

100%

Add/Change Orders

# Charts Audited

Yes

No

N/A

% of compliance

 

Diagnosis written for new care, service, and/or treatments

13

4

9

7

31%

 

Non-routine supplies included in mod when treatment changes

5

4

1

15

80%

 

CLINICAL INDICATORS

SN

PT

 

# Charts Audited

Yes

No

N/A

% of compliance

# Charts Audited

Yes

No

N/A

% of compliance

 

Frequency and duration of visits are consistent with established orders.

20

18

2

 

90%

8

6

2

 

75%

 

Pain assessment and interventions documented on every visit    (if applicable)

20

11

9

 

55%

8

3

5

 

38%

 

If miss visit note completed was physician notified and documented

8

7

1

12

88%

2

 

2

6

0%

 

Complete skilled assessment was documented each visit note per POC.

20

18

2

 

90%

8

7

1

 

88%

 

DM/Foot Care assessment/instruction documented using EBP (if applicable)

4

3

1

16

75%

 

 

 

8

 

 

Abnormalities documented and reported to physician and clinical supervisor

10

10

 

10

100%

1

1

 

7

100%

 

If Patient at High Risk for pressure ulcers (per Braden Scale) was off loading education/DME provided and documented

4

 4

 

16

 100%

 

 

 

 8

Revised 1/2020