Chart Audits

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Post-Acute Care and Home Health Care

What happen to the Acute-Care organization's Discharge Planners and the Post-Acure Care Home Health Care Community Liaison? These roles have disappeared to be replace ....

Encouraging Physicians to Properly Complete Face to Face Encounters

Physicians may find themselves being denied payment by CMS for Case Management overseen fees and office visits due to poor documentation in their patient\\\'s medical record.

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..."

Submitting Request for Records to Medicare Picture

Submitting Request for Records to Medicare

More than 47% of denials by PalmettoGBA for the period of 10/2017-12/2018 were related to...... Read More...

Tips

Patient-Driven Grouping Model (PDGM)-Effective January 1, 2020 CMS Home Health Payment Methodology. Picture

Patient-Driven Grouping Model (PDGM)-Effective January 1, 2020 CMS Home Health Payment Methodology.

Have you downloaded the CMS PDGM Excel file from the CMS Home Health Agency Center?

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?

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...

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