Nursing Chart Review Page 2

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P
N
:
M
R
#:
ATIENT
AME
EDICAL
ECORD
ASSESSMENT / REASSESSMENT (OASIS)
24. Assessment completed within timeframe per policy/regulation
Yes
No
N/A
25. Reassessment completed according to policy/regulation
Yes
No
N/A
ADMIT INFORMATION
26.
All admission paperwork is completed and signed?
Yes
No
N/A
27.
If Advance Directive is completed, copy in the chart? Documentation present?
Yes
No
N/A
HOME HEALTH AIDE
28. Specific documentation on assessment on admit or recert to justify need for HHA.
Yes
No
N/A
29. HHA frequency is consistent with Plan of Care and verbal orders.
Yes
No
N/A
30. Documentation to explain all missed visits with physician notification.
Yes
No
N/A
31. Any problems reported by HHA are followed up by case manager or clinical supervisor.
Yes
No
N/A
32. The HHA care plan is developed/revised based on the patient’s needs according to the
Yes
No
N/A
plan of care or as patient changes warrant.
33. HHA supervisory visit according to plan of care or policy.
Yes
No
N/A
34. The HHA follows the care plan and documents performance of assigned tasks.
Yes
No
N/A
35. The HHA reports problems to appropriate personnel.
Yes
No
N/A
36. Vital sign parameters are on care plan when aide is assigned to take vital signs.
Yes
No
N/A
37. Notes complete and signed. Filing according to policy.
Yes
No
N/A
DISCHARGE
The physician is notified of discharge.
Yes
No
N/A
38.
A discharge summary is complete
Yes
No
N/A
39.
40. 5 day notice to physician and patient.
Yes
No
N/A
(
Additional comments on the back)
HCL / Chart Review - Nursing
Rvd. 051306

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