In reviewing over 1,000 patient files in the past six years, here is a list of some of the most common patient file deficiencies I have found.

One of the primary issues I have found has to do with the lack of patient signatures for all of the proper documentation as required. Issues such as the patient not receiving:

• their educational materials which could be a manufacturer booklet or generic booklet for that piece of equipment
• the current Medicare DMEPOS Supplier Standards or permitted statement
• the patient and/or caregiver have not been educated on the proper use of that piece of equipment
• the patient has not received the organization’s complaint policy or process information
• the patient understands their financial responsibility in writing

Another issue certainly worth mentioning is with physician’s orders/scripts. These orders need to be:

• current, correct and complete for each piece of equipment, and available for review
• if the physician order is incomplete, clarify the information and request a new order with the required information
• if this is an oxygen order, the physician order/script must designate oxygen conserving device if you are providing an OCD to the patient
• if your state requires a new physician order/script annually/every 365 days you need to set up a process to ensure you have received the new order timely

Request the checklist below to help your staff audit patient files for the required documentation, ensuring it is complete and accurate. If the documents are not complete, making a note on the checklist allows you to either forward a copy of that document to the proper staff member(s) for correction or clarification, or request the required document.

Example: You receive a physician order/script for oxygen at 2LPM via nasal cannula, but there is no duration/frequency (continuous, nocturnal, etc.) notated on the order. This order needs clarification from the ordering physician and a complete written order needs to be obtained for your patient record. 

Certain states such as Florida have governing bodies (AHCA) that require additional documentation in the patient record. Make certain you know your state's requirements. Not all patient records may contain all documents listed below. This list may not be all inclusive. Ensure you know your payer source requirements and customize your checklist/audit tool to meet all accreditation standards, as well as any federal and state requirements. 

Once the patient record is in place, to guarantee you are maintaining the record properly, institute a process for the following: 

• When a new piece of equipment is ordered by the physician, ensure you have:
  • a current and complete order
  • if the order is not complete, clarify the information and request a new order with the required information
  • you have all of the proper documentation prior to the billing process
• If you are required to obtain a new written physician order every 365 days, ensure you have a process in place to request this order within the proper timeframe.
• If a CMN is needed after the first 365 days, ensure you have a process in place to ensure this is requested and received timely. 

Remember your state may have additional requirements such as providing the patient or caregiver with the state’s phone number(s) or possibly an emergency action plan for every county you service. Know your state’s regulations.

Although this may seem like a tedious process, once it is set up it flows easily. A checklist of the items needed within the patient file will help your staff maintain patient records in excellent condition. As you complete file audit forms, take what results were found to the company quality improvement meetings. Report on those steps that are going well and those that might need improvement.