Policy Manual sample

MDT Home Health Care Agency, Inc. QUALITY ASSURANCE EVALUATION PATIENT'S NAME: ________________________________________________________ PERIOD IN REVIEW: DATE OF EVALUATION: NAME AND TITLE OF EVALUATOR: _______________________________________ ITEMS ASSESSED GRADE EXCELLENT ABOVE AVERAGE AVERAGE BELOW AVERAGE 1. Staff attendance rate 2. Staff punctuality rate 3. Staff ability to record relevant notes 4. Staff ability to communicate in legible, professional manner 5. Staff knowledge of professional procedures 6. Staff ability to relate to patient, doctor, patient's family and other professionals 7. Overall impression regarding quality of care Final Comment Home Health Agency - - Skilled Professional Services D-12