QAPI Program Utilization_Manual

SIGN UP PACKAGE CHECK LIST Patient’s Name:_____________________________________ Med. Record: _________________ Period of evaluation: __________________ - _________________ ITEMS English Spanish Advance Directives, Patient’s Handbook Bill of Rights/Responsibilities Care Plan, patient participation Consent to Treatment (Agreement) Contract Agency Agreement, fully executed Disaster/Emergency Plan, classification, registration if needed Aide Care Plan Hurricane warning, instructions Grievance Procedure Medication Profile Nutritional Status (OASIS). Blood Sugar log if applicable Nursing Assessment (OASIS) Nursing Note (initial) Payment authorization (SS Form, Medicare payer questionnaire) Patient History (pay source) Patient choice form if needed, Abuse/Hot line phones explained Referral Intake form Safety check list (OASIS) Team Communication, Weekly/itinerary OASIS Assessment Privacy Act Statement: OASIS/HIPAA Comments: _______________________________________________________________________ _________________________________________________________________________________ Staff’s Signature: _____________________________________ Date: _______________________ 36