Home Health Audit Form Sample Details

If you're a home health care provider, then you know that it's important to keep track of your patients' progress. A home health audit form can help make this process easier by tracking information such as medication use, treatments, and vital signs. The form can also help identify any problems or concerns so that they can be addressed quickly. By using a home health audit form, you can ensure that your patients are getting the best possible care.

This article contains information regarding home health audit form. You will have the estimated time you'll need to fill in the form and several further details.

QuestionAnswer
Form NameHome Health Audit Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other nameshome health chart audit tool, home care audit checklist, home health chart audit form, home health chart audit tools

Form Preview Example

Home Health Medical Records Audit Form

(Updated for CY2013)

Auditor’s Name/Title: ________________________________________________________

 

Date: ___________________________

 

Yes

No

N/A MR #

Comments

Admission

1.Patient Referral Sheet Complete Timely Initiation of Care

Face to Face Encounter Within 90 Days To SOC

Face to Face Encounter Within 30 Days To SOC

History of Physical Present

2.Pre‐Admit Physician Order –

Signed, Dated or VO signed by RN + Physician

3.Primary DX M1020 Secondary M1022 M1022

M1022

M1022

M1022

M1022

Any Codes 401.1 Any Codes 401.9

All DX Supported & Sequenced Properly

4.Medication (N)ew and (C)hanged Interactions – Included Food/OTC

5.Admission consistent with Agency Admission Policies

6.Patient/Client Service Agreement – Signed, Dated & Complete

7.Insurance Screening Form – Signed & Complete

8.Medical Necessity Noted

9.Acknowledgement, Receipt & Explanation of the Items Below:

a.Home Care Patient Rights & Responsibilities

b.Privacy Act Statement‐Health Care Care Records

c.Complaint Procedure

d.Authorization for Use or Disclosure of Health Information (if applicable)

e.Statement of Patient Privacy Rights (OASIS)

f.Consent for Collection & Use of Information (OASIS)

Yes

No

N/A

MR #

Comments

 

 

 

 

 

g.Emergency Preparedness Plan/Safety Instructions

h.Advance Directives & HHABN

10. Complete Post Evaluation –

D/C Summary Report by RN/PT/OT/ST on:

a. Start of Care

b. Resumption of Care

c. Recertification

Plan of Care 485

11.Plan of Care Signed & Dated by Physician Within 30 Working Days or State Specific days‐ ________

12.Diagnoses Consistent with Care Ordered

13.Orders Current

14. Focus of Care Substantiated

15.Daily Skilled Nurse Visit Frequencies with Indication of End Point

16. Measurable Goals for Each Discipline

17. Tinetti or TUG Completed at SOC

18. Recertification Plan of Care Signed &

Dated Within 30 Days or State Required

Time

19.BiD Insulin Visits Documented with Vision, Musculoskeletal Need, Not Willing/Capable Caregiver. MSW Every Episode

20. Skilled Nurse Consult

Medication Profile Sheet

21.Medication Profile Consistent with the 4 485

22. Medication Profile Updated at

Recertification, ROC, SCIC, Initialed &

Dated

23.Medication Profile Complete with Pharmacy Information

Physician Orders/Change Verbal Orders

24. Change/Verbal Orders Include Disciplines, Goals, Frequencies, Reason for Change, Additional Supplies as Appropriate

25.Change Orders Signed & Dated by Physician Within 30 Working Days

OASIS Assessment Form

26. Complete, Signed & Dated by:

___________________________

27.M2200 Answer Meets the Threshold for a Medicare High Case Mix Group

28. M1020 & M1022 Diagnoses & ICD‐9 are Consistent with the Plan of Care

Yes

No

N/A

MR #

Comments

 

 

 

 

 

29.All OASIS Assessments Were Exported Within 30 Days

30. OASIS Recertifications Were Done

Within 5 Days of the End of the Episode

31.All OASIS Were Reviewed for Consistency in Coordination with the Discipline Who Completed the Form

Skilled Nursing Clinical Notes

32. Visit Frequencies & Duration are Consistent with Physician Orders

33.Orders Written for Visit Frequencies/ Treatment Change

34. Homebound Status Supported on Each Visit Note

35.Measurable Goals for Each Discipline with Specific Time Frames

36. Frequency of Visits Appropriate for Patient’s Needs & Interventions Provided

37. Appropriate Missed Visit (MV) Notes

38. Skilled Care Evident on Each Note

39. Evidence of Coordination of Care

40. Every Note Signed & Dated

41. Follows the Plan of Care (485)

42. Weekly Wound Reports are Completed

43. Missed Visit Reports are Completed

44. Pain Assessment Done Every Visit with Intervention (If Applicable)

45.Abnormal Vital Signs Reported to Physician & Case Managers

46. Evidence of Interventions with Abnormal Parameters/Findings

47.Skilled Nurse Discharge Summary/ Instructions Completed

48. LVN Supervisory Visit Every 30 Days by Registered Nurse

Certified Home Health Aide

49.Visit Frequencies & Duration Consistent with Physician Orders

50. Personal Care Instructions Documented,

Signed & Dated

51.Personal Care Instructions Modified as Appropriate

52. Notes Consistent with Personal Care Instructions Noted on the CHHA Assignment Sheet Completed by the RN/PT/ST/OT

53.Notes Reflect Supervisor Notification of Patient Complications or Changes

54. Visit Frequencies Appropriate for Patient Needs

Yes

No

N/A

MR #

Comments

 

 

 

 

 

55. Each Note Reflects Personal Care Given

56. Supervisory Visits at Least Every 14 Days by RN or PT

57. Every Note Signed & Dated

PT

58. Assessment Includes Evaluation,

Care Plan & Visit Note

59.Evaluation Done Within 48 Hours of Referral Physician Order or Date Ordered

60. Visit Frequencies/Duration Consistent with Physician Orders

61.Evidence of Need for Therapy/Social Service

62. Appropriate Missed Visit (MV) Notes

63. Notes Consistent with Physician Orders

64. Evidence of Skilled Service(s) Provided

in Each Note

65.Treatment/Services Provided Consistent with Physician Orders & Care Plan

66. Notes Reflect Supervisor & Physician Notification of Patient Complications or Changes

67.Specific Evaluation & “TREAT” Orders Prior to Care

68. Verbal Orders for “TREAT” Orders Prior to Care

69.Homebound Status Validated in Each Visit Note

70. Notes Reflect Progress Toward Goals

71. Evidence of Discharge Planning

72. Evidence of Therapy Home Exercise

Program

73.Discharge/Transfer Summary Complete with Goals Met/Unmet

74. Assessment & Evaluation performed by Qualified Therapist Every 30 Days

75.Supervision of PTA/OTA at Least Every 2 Weeks

76. Qualified Therapy Visit 13th Visit (11, 12, 13)

77.Qualified Therapy Visit 19th Visit (17, 18, 19)

78. Every Visit Note Signed & Dated

SLP

79.Assessment Includes Evaluation, Care Plan & Visit Note

80. Evaluation Done Within 48 Hours of Referral Physician Order or Date Ordered

81.Visit Frequencies/Duration Consistent with Physician Orders

Yes

No

N/A

MR #

Comments

 

 

 

 

 

82. Evidence of Need for Therapy/Social Service

83. Appropriate Missed Visit (MV) Note

84. Notes Consistent with Physician Orders

85.Evidence of Skilled Service(s) Provided in Each Note

86. Treatment/Services Provided Consistent with Physician Orders & Care Plan

87.Notes Reflect Supervisor & Physician Notification of Patient Complications or Changes

88. Homebound Status Validated in Each Visit

Note

89. Notes Reflect Progress Toward Goals

90. Evidence of Discharge Planning

91.Evidence of Therapy Home Exercise Program

92. Discharge/Transfer Summary Complete with Goals Met/Unmet

93.Supervision of PTA/OTA at Least Every 2 Weeks

94. Every Visit Note Signed & Dated

Miscellaneous

95.Progress Summary Completed(30‐45Days) Each Episode Signed & Dated

96. Field Notes are Submitted & Complete

97. Chart in Chronological Order

98. Chart in Order per Agency Policy

99.Patient Name & Medical Records Number on Every Page

100. Physician Orders are Completed/ Updated for Clinical Tests Such as:

a. Coumadin: Protime/INR

b. Hemoglobin A1C

c. CBC, Metabolic Panel, CMP

d. Others: _______________________

101.Communication with Physician Regarding Test Results

Process Measures:

Timely Initiation of Care

Influenza Received

PPV Ever Received

Heart Failure

DM Foot Care & Education

Pain Assessment

Pain Intervention

Depression Assessment

Medication Education

Falls Risk Assessment

Pressure Ulcer Prevention

Pressure Ulcer Risk Assessment

Additional Comments/Recommendations

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

THE FOLLOWING IS APPLICABLE FOR QUARTERLY MEDICAL REVIEW REPORT

REVIEWED AND SIGNED BY THE FOLLOWING DISCIPLINARY REPRESENTATIVE

______________________________________

______________________________________

Registered Nurse

Occupational Therapist (If Applicable)

______________________________________

______________________________________

Physical Therapist (If Applicable)

Speech Language Pathologist (If Applicable)

______________________________________

______________________________________

Medical Director

MSW (If Applicable)

MR # ______________________

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