QAPI Program Utilization_Manual

PROGRESS NOTES QA CHECK LIST REVIEW (every 14 days) Patient’s Name: ______________________________________ Med. Record: ____________ Evaluation period: ___________________ to _______________ SKILLED SERVICES : 9 Disease process instructions 9 Medication instructions (action, s/e, compliance, interaction with over the counter meds), Updates, D/C 9 Glucometer teachings, test performed 9 Glucose levels, Glucometer calibration (at least weekly) 9 Diabetes Management, instructions, diet 9 Wound care, weakly addendum, instructions, unfection control, universal/standards precautions 9 Wound record, procedure as per POC, MD orders, updates. 9 Wound supplies orders, invoices 9 D/C planning, instructions 9 Physician contacted as needed, new order obtained if needed. Date of last contact: _____________ 9 Vital sign recorded/observations all systems assessment 9 Following Patient assessment guidelines 9 Foley maintenance: date changed, description of foley as POC 9 Patient/S.O. at least weekly verify why/unable to wound care, diabetic care, inj. Administration 9 Case Conference (at least q30days) 9 Team Communication documented 9 Patient identified prior treatment, Privacy/HIPAA followed 9 Any portion of plan assigned to LPN, PTA, OTA, STA were discussed, documented 9 Pain management in place, rate, place, relief measures 9 Fall prevention plan, explained to patient 9 Oxygen safety, use of HME if any 9 Safety precautions followed 9 60 day summary as needed 9 Supervision of HHA/CNA, PTA, OTA, STA as per policy 9 Homebound status documented, verified 9 Credentials/Title in all signatures (clearly) 9 PT Notes interventions following POC/485, documented ROM, Balance, Pain rate, exercises, Ambulation 9 OT Notes intervention following POC/485, documented outcomes, pain management, rate. 9 ST notes intervention/procedures following POC/485, documented voice disorders treatment, oral rehabilitation 9 MSW notes interventions following POC/485, documented assessment of social & emotional factors, Referrals if any. 9 Nutritional, diet documented, instructions 9 Itinerary used, signed correctly 9 Vital sign out of range (Panic value), reported to Physician, new order obtained: _________________________ 9 Other: __________________________ ________________________________ ________________________________ NO SKILLED SERVICES: 9 All activities performed following HHA/CNA plan of Care, and POC/485 (MD orders) 9 Personal Care, Bath as POC/485 9 Hygiene & Grooming as POC/485 9 ADL’s, Procedures as per POC/485, HHA Care Plan 9 Vital signs recorded as POC/485, HHA Plan 9 Activities, ambulation, transfer documented, match POC/485, HHA Plan of Care 9 Nutritional, Diet followed as Plan of Care, 485 9 Assisting with self administration of Meds documented, patient informed, HHA/CNA with 2 hrs training. 9 Supervision every ___ days (14 or 60), fully documented, form in place 9 Any significant finding reported to Nurse/Therapist/Agency 9 Team Communication form used 9 Credential/Titles in all signatures 9 Itinerary used, signed correctly 9 Other: __________________________ ________________________________ ________________________________ Comments: __________________________________ __________________________________ QA Staff name: _____________________ Staff’s Signature/Title: ________________ Date: ______________ 35