Policy Manual sample

MDT Home Health Care Agency, Inc. QUALITY ASSURANCE FORM FOR REVIEW OF CLINICAL RECORDS, Report to BD Date of Evaluation: Name of Staff making evaluation:__________________________________________ CRITERIA SATISFACTOR Y UNSATISFACTOR Y 1. Case assignment and management is appropriate, adequate and consistent with the patient care plan, medical regime, and patient needs. 2. Nursing, services are consistent with professional community health nursing standards. 3. Nursing and other services provided to the patient are coordinated. 4. All services and outcomes are completely and legibly documented, dated and signed IN TIME, in the clinical service record. 5. Confidentiality of patient data is maintained. 6. Findings of the quality assurance programs are used to improve services. 7. Were cases assigned to staff as stated in the policy? 8. Were cases assessed within 48 hours of acceptance of the cases (including all discipline ordered). 9. Were SN, Therapy, and HHA Visits made on a timely and professional manner as are contained in the manual? 10. Were SN, Therapy, and HHA visit records documented to show the time and duration of each visit? 11. Did RN records on patients' medications show the times and frequencies of such medications? 12. Did RN's supervise all medications? 13. Were staff's notes turned in every week as stipulated in the manual? 14. Was there evidence that agency staff availed the patients of a copy of the Bill of Rights in accordance with section 504 of the Civil Rights Acts of 1964? 15. Did staffs notes reflect quality and professional management of the patient? 16. Did the agency develop a Plan of Treatment that was jointly signed by the physician and agency staff? 17. Did Agency staff adhere to the Plan of Care in providing services to the patient? 18. Was the Patient care plan carefully developed, written (identified for problems, solutions, goals, and re-evaluation dates) 19. Did the patient sign a consent for treatment form? 20. Was the Plan of Care reviewed and updated for each certification period.? 21. Upon discharge, was a discharge summary sent to the physician to stipulate plans for continuing care? 22. Was there a discharge letter sent to the patient to advise of agency's termination of services and reasons for such termination? 23. Were there clinical records to reflect team conferences, 60 day summary, and conferences with the physician and with the patient as well? Final Comment: ____________________________________________________________________________ ____________________________________________________________________________ Signature: ______________________________ Home Health Agency - - Skilled Professional Services D-20