Rehabilitation Documentation Review
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Facility: |
Date: |
Reviewed by: |
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Patient: |
Therapist: |
Disc. OT PT ST |
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Key: (+) = Present/Meets |
(N) = Not Applicable |
(■) = Criteria Not Met |
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Areas to Review |
Comments | ||||
|---|---|---|---|---|---|
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MD Order |
1 |
Referral / order is current? | |||
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2 |
Referral / order signed & dated by the physician? | ||||
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3 |
Extension or other required order is in the chart? | ||||
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Evaluation/POC |
4 |
Evaluation is complete and documented timely? | |||
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5 |
Plan of Care signed and dated by physician within 30 days of Start of Care? | ||||
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6 |
Reason for referral is clearly stated and supports therapy intervention? | ||||
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7 |
Medical & treatment diagnoses are clearly stated and support Plan of Care? | ||||
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8 |
Prior level of function supports treatment? | ||||
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9 |
Medical history is comprehensive and relates to reason for treatment? | ||||
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10 |
Functional testing completed and limitations clearly stated? | ||||
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11 |
Therapist’s clinical assessment/impression documented? | ||||
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12 |
Goals are specific, measurable, functional, and have time frames? | ||||
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13 |
Plan of Care includes interventions/procedures related to the goals? | ||||
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14 |
Frequency and duration are appropriate and specific? | ||||
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Progress Notes |
15 |
Daily / treatment encounter notes present for all dates therapy delivered, including treatment rendered on day of evaluation? | |||
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16 |
Progress reports completed by therapist as required by payer and applicable state practice acts? | ||||
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17 |
Number of treatments is supported by the frequency/duration? | ||||
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18 |
Goals are addressed in encounter notes and progress reports? | ||||
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19 |
Encounter notes reflect skilled interventions and time billed? | ||||
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20 |
Patient’s response to treatment is documented? | ||||
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21 |
Education of patient, staff, caregiver, or family is clearly documented? | ||||
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22 |
Progress reports support need to continue treatment? | ||||
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23 |
Active participation by therapist at least every10 visits for Med B? | ||||
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24 |
Co-signatures are recorded as required by practice act? | ||||
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Updated POC/DC Summary |
25 |
Updated Plan of Care/ Recertification signed and dated by the physician? | |||
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26 | Discharge summaries are filed in the medical record and completed by clinician timely? | ||||
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27 | Discharge recommendations & referrals are made as appropriate? | ||||
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28 | Progress clearly documented? Comparison made from initial status? | ||||
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29 | Goals are addressed with explanations for goal(s) not attained? | ||||
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30 | Need for medically necessary, skilled service is documented? | ||||
Total # Correct ________/________=________%
Action Plan Recommended □ Yes □ No
Comments/Recommendations:
Reviewer’s Signature: ___________________________________ Date: _______________________