9009 - Durable Medical Equipment Medical Records Audit Form by compliancedoctor

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									        DURABLE MEDICAL EQUIPMENT MEDICAL RECORDS AUDIT FORM

Client MR#:                                            SOC Date:                  Discharge Date:

Review Period: From:                            To:

                                    Please comment on any “No” or “NA” Answers:

                                                      Yes   No   NA                  Comments

                     Admission

1. Intake/referral form complete

2. Admission consistent with company
   admission policies

3. Authorization form completed, signed and
   dated

4. Acknowledgment of receipt of Supplier
   Standards signed and dated

5. Advance Directives addressed/present or
   copy requested, if appropriate

6. Client Bill of Rights and Responsibilities given
   to client

7. Home safety evaluated

8. Waste disposal and infection control
   addressed

9. Actions to take in the event of an emergency
   addressed

10. Type and frequency of services to be
    provided addressed

11. Authorization to Treat Form signed

12. Rental/Sales Agreement signed



      Plan of Care/CMN/Physician Orders

13. Plan of care/CMN signed and dated by
    physician within _____ days

14. Diagnoses consistent with treatment/services
    ordered

15. Orders current


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DURABLE MEDICAL EQUIPMENT MEDICAL RECORDS AUDIT FORM (continued)

Client MR#:                                             SOC Date:                  Discharge Date:
Review Period: From:                             To:
                                     Please comment on any “No” or “NA” Answers:

                                                       Yes   No   NA                  Comments

16. Orders appropriate for treatment/services to
    be rendered

17. Appropriate diagnoses and codes for
    coverage and reimbursement

18. All entries dated and signed

19. Measurable goals for care/treatment/services
    with specific time frames

20. Recertification plan of care/CMN signed and
    dated by physician prior to recertification date

21. Client/family education documented



              Change/Verbal Orders

22. Change/verbal orders include care/treatment/
    services, goals, frequencies, reason for
    change, additional supplies as appropriate

23. Change orders signed and dated by
    physician within _____ days



                   Medications
        (if Clinical Respiratory Services
                ordered/provided)

24. Medication Administration Record (MAR)
    completed, as per company policy

25. MAR
								
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