Policy Manual sample

MDT Home Health Care Agency, Inc. CLINICAL RECORDS - SUMMARY REPORTS- COMMUNICATION NOTE Patient's name: ___________________________________________________________ Date of this report: Medical Record: _______________ Name of reporting staff: _______________________________________________________ Diagnosis: __________________________________________________________________ ___________________________________________________________________________ Date MDT Home Health Care Agency, Inc. started services to patient:_______________________ Brief summary/Communication: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ (to include major services rendered, patient's response to treatment, any significant findings/communication, and recommendations to the physician) Signed: * This is a sample form, may be replaced by Electronic, software developed form Home Health Agency - - Skilled Professional Services C-25