QAPI Program Utilization_Manual

CLINICAL RECORD/UTILIZATION REVIEW Client ID #: ____________________________ Review Period: From: ___________________ Through: _________________________ Service(s) Provided: ________________________ Frequency/Duration: ________________ Instructions: Fill in with [X] when “complete”, [O] when “not complete”, [N/A] when “not applicable” Admission Review: Start Of Care Date: ________________________ 1. [ ] Client Profile 2. [ ] Request for Service 3. [ ] Agreement for Service 4. [ ] Consent for Care/Release for Information/Authorization of Benefits 5. [ ] Initial Nursing Assessment 6. [ ] Plan of Treatment signed by physician within 14 days 7. [ ] Plan of Care: [ ] a. Skilled Nursing [ ] b. Therapy/Social Service [ ] c. Aide/Homemaker 8. [ ] Medication Profile 9. [ ] Coordination of Service [ ] Initial Case Conference On-Going Review: 10. [ ] Plan of Treatment recertified every 60 days and signed by physician prior to recertification period 11. [ ] Coordination of Services: [ ] a. Client Progress Note to document skilled supervisory visits according to policy [ ] b. Case Conference: Interim [ ] c. Physician Summary monthly/every 60 days and sent to physician [ ] d. Verbal Orders signed by physician with corresponding communication note 12. [ ] Changes in the Plan of Treatment are incorporated, reviewed/updated by RN every 60 days and prn into [ ] a. Plan Of Care [ ] b. Medication Profile 13. [ ] Nursing/Therapy/Aide/Homemaker Notes and appropriate flowsheets are completed, signed with title, and incorporated into the clinical record 14. [ ] Aide Plan of Care reviewed/updated every 60 days and prn 15. [ ] Aide Progress Notes adheres to the Plan of Care 16. [ ] Aide Supervisory visits documented according to policy 17. [ ] The Nursing/Therapy/Aide services documented match frequency and duration of services ordered Discharge Review: Discharge Date: _______________________ 18. [ ] Coordination of Services [ ] a. Discharge Case Conference [ ] b. Verbal Order [ ] c. Communication Note 19. [ ] Discharge Summary completed within 14 days of discharge Reviewer’s Conclusions and Recommendations: 20. [ ] Reviewer’s opinion on how client’s needs were met and services integrated: Unmet need apparent: [ ] Yes [ ] No Service Integrated: [ ] Yes [ ] No [ ] Not Applicable 21. [ ] Reviewer’s comments/summary: ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ _______________ 22. [ ] Reviewer’s decision on the appropriateness of the Plan of Care as related to the client’s condition and clinical course: [ ] a. appropriate [ ] b. inadequete information [ ] c. over utlization [ ] d. under utilization [ ] e. unable to decide 23. [ ] Reviewer’s recommendation regarding further action: [ ] a. no action [ ] b. Director of Clinical Services [ ] c. Quality Assurance Committee [ ] d. other (specify): _________________________________________________________________ Reviewer’s Signature/Title: ______________________________ Date:___________________ Actions Taken: __________________________________________________________________________________________________ 40