Policy Manual sample

MDT Home Health Care Agency, Inc. HOME HEALTH CARE AGENCY NOTIFICATION OF CLIENT’S CLINICAL RECORD DEFICIENCIES Client’s Name: ______________________________________________________ Client’s clinical record number: __________________________________________ Client’s case manager: ________________________________________________ Client’s attending physician: ____________________________________________ Client’s principal diagnosis: _____________________________________________ Client’s admission date: ________________________________________________ Client’s discharge date: ________________________________________________ Name of individual notified of client’s clinical record deficiency(ies): ___________________________________________________________________ Client’s clinical record deficiency(ies):_____________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ______________________________ ___________________ Signature of Individual who performed Date of Signature Home Health Agency - - Skilled Professional Services D-22