QAPI Program Utilization_Manual

MEDICAL RECORDS CORRECTION POLICY OASIS ASSESSMENT CORRECTIONS PURPOSE: To properly record changes/corrections in the patient medical record. POLICY: Any person authorized by our Agency to make record entries may correct errors in documentation, spelling, or add inadvertently omitted clinical entries. Documentation and/or spelling errors are corrected by drawing a single line through the incorrect information, writing “error” by the crossed out area, and documenting the date the correction is made. The initials of the person making the correction must be recorded after the date. Late entries will be recorded on the next chronological line on the chart with the date and time of the late entry recorded. The initials of the person making the late entry must be recorded at the late entry site. The use of white out or erasing of incorrect information is not allowed. In addition, any attempts to squeeze a late entry into the margin or between lines is not allowed. OASIS Assessments Corrections: PROCEDURES: §COMPREHENSIVE ASSESSMENT AND OASIS COLLECTION 1. All mandatory OASIS items will be incorporated into the comprehensive assessment. The assessment (paper or computerized) will be completed within the required timeframes. 2. OASIS data for the Medicare Prospective Payment System (PPS) will be reviewed for accuracy prior to the lock date. 3. Corrections can be made to the OASIS data set by th e clinical staff or an office-based RN coor dinator using the following method: a. No changes will be made without the knowledge and agreement of the clinician completing the OASIS; b. Corrections are to be made prior to the data being locked; c. Once the corrections have been made, a Clinical Note will be completed stating: 1) date of the file; 2) type of file; 3) name of the clinician; 4) the specific changes made; 5) rationale for the change, as applicable; and 6) the name and discipline of the person making the correction(s). d. The Agency’s sof tware will also track all changes and by whom in the revision history section of the assessment. 4. The software will lock the OASIS data on the seventh day after the assessment date (MO090). 32