Healthcare Compliance Forms and Tools

Facility:

Date:

Reviewed by:

Patient:

Therapist:

Disc.‍‍‍ OT‍‍‍ PT‍‍‍ ST

Key: (+) = Present/Meets

(N) = Not Applicable

(■) = Criteria Not Met

MD Order

1

Referral/order is current?

2

Referral/order signed and dated by the physician?

3

Extension or other required order is in the chart?

Evaluation/Plan of Care

4

Evaluation is complete and documented timely?

5

Plan of care signed and dated by physician within 30 days of start of care?

6

Reason for referral is clearly stated and supports therapy intervention?

7

Medical and treatment diagnoses are clearly stated and support the plan of care?

8

Prior level of function supports treatment?

9

Medical history is comprehensive and relates to reason for treatment?

10

Functional testing completed and limitations clearly stated?

11

Therapist’s clinical assessment/impression documented?

12

Goals are specific, measurable, functional, and have time frames?

13

Plan of care includes interventions/procedures related to the goals?

14

Frequency and duration are appropriate and specific?

Progress Notes

15

Daily/treatment encounter notes present for all dates therapy delivered, including treatment rendered on day of evaluation?

16

Progress reports completed by therapist as required by payer and applicable state practice acts?

17

Number of treatments is supported by the frequency/duration?

18

Goals are addressed in encounter notes and progress reports?

19

Encounter notes reflect skilled interventions and time billed?

20

Patient’s response to treatment is documented?

21

Education of patient, staff, caregiver, or family is clearly documented?

22

Progress reports support need to continue treatment?

23

Active participation by therapist at least every 10 visits for Medicare Part B?

24

Co-signatures are recorded as required by practice act?

Updated Plan of Care/Discharge Summary

25

Updated plan of care/recertification signed and dated by the physician?

26

Discharge summaries are filed in the medical record and completed by clinician timely?

27

Discharge recommendations and referrals are made as appropriate?

28

Progress clearly documented? Comparison made from initial status?

29

Goals are addressed with explanations for goal(s) not attained?

30

Need for medically necessary, skilled service is documented?