QAPI Program Utilization_Manual

CLIENT’S CLINICAL RECORD DISCHARGE ANALYSIS POLICY All client’s clinical records of discharged clients are complied and analyzed for compliance with accepted professional and legal standards. PURPOSE To ensure client’s clinical records contain complete legal documentation regarding client’s Home Health Care. PROCEDURES 1. Client’s clinical records of discharged clients are submitted to the Administrative Assistant for client’s clinical record discharge analysis. 2. The administrative assistant: a. Documents a client’s discharge on the Record of Home Health Care Agency Visits forms by filing in the following information (See Client’s Clinical Record Index Card and Client’s Clinical Record Discharge Analysis Form). 1. Discharge date. 2. Place to which client discharged. 3. Reason for discharge. 4. Services client received. 5. Total number of client visits. b. Documents the client’s discharge on the Client’s Clinical Records Index Cards (See Clienrs Clinical Records Index Card). c. Removes the client’s clinical record from the clinical record holder. d. Initiates the Client’s Clinical Record Discharge Analysis form (See Client’s Clinical Record Discharge Analysis Form). e. Arranges the client’s clinical record forms in appropriate chart order, filing them chronologically if there is more than one from of the same type. f. Analyzes the client’s clinical record for record deficiencies, as indicated on the Client’s Clinical Record Discharge Analysis form. g. Documents any record deficiencies on the Client’s Clinical Record Discharge Analysis form. h. Notifies the appropriate individual of any record deficiencies using the Notification of Client’s Clinical Record Deficiencies form (See Notification of Client’s Clinical Record Deficiencies Form). i. Places the completed Client’s Clinical Record Discharge Analysis form in the client’s clinical record. j. When the record deficiencies are corrected, files the client’s clinical record in the inactive client’s clinical record file, following Client’s Clinical record filing system. 25