9008 - Medical Record Audits by compliancedoctor

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									    SUBJECT:         MEDICAL RECORD AUDITS                                 REFERENCE #9008
                                                                           PAGE: 1
    DEPARTMENT: DURABLE & HOME MEDICAL EQUIPMENT                             OF: 3
                                                                           EFFECTIVE:
    APPROVED BY:                                                           REVISED:


PURPOSE:

        To evaluate whether:

                 Documentation in the medical record reflects the quality of client care, treatment
                  and/or services provided

                 Services and equipment provided are consistent with the scope of services defined
                  by the company and meet the needs of the client in his/her environment in
                  frequency, type and duration, and contribute to positive client outcomes

                 The client is appropriately assessed for acceptance and that equipment set-up and
                  service delivery are initiated in a timely manner

                 Services are coordinated and involve all team members

                 Services provided are consistent with the plan of care

                 Physician orders are obtained in a timely manner and adhered to in the provision of
                  service and equipment

                 The plan of care/physician’s prescription contains the required data elements to
                  support payment of the claim and direct the provision of service and equipment

                 The client is appropriately instructed regarding equipment use and safety factors

                 Follow-up activities are consistent with company policy, adequate to meet client
                  needs and appropriately recorded

                 Discharge planning activities are initiated in a timely manner

POLICY:

        A sampling of client records shall be reviewed by Performance Improvement Committee
         members on a quarterly basis.

        Client confidentiality is maintained throughout the data collection and summary reporting
         processes.


© The Compliance Doctor, LLC
    SUBJECT:          MEDICAL RECORD AUDITS                                  REFERENCE #9008
                                                                             PAGE: 2
    DEPARTMENT: DURABLE & HOME MEDICAL EQUIPMENT                               OF: 3
                                                                             EFFECTIVE:
    APPROVED BY:                                                             REVISED:


        Medical records of clients receiving clinical respiratory services are reviewed by licensed
         personnel (Respiratory Therapy or Nursing).

        Medical Record Audits are an ongoing, integral part of the company’s Performance
         Improvement program.

PROCEDURE:

        A sample of 10% of active client records and 10% of records of clients discharged within
         the past three (3) months shall be chosen for the sample. (Minimum of 30 records or 10%
         in each category, whichever is greater, shall be included.)

        The records chosen shall include clients identified as high-risk, high-cost and
         problem-prone by __________________. These records shall include, but not be limited
         to, the following:

                 Records of clients requiri
								
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