Patient Record Review

One of the most important tasks a surveyor will perform during your organization’s survey is the patient record review. Whether this is done by combing through manila or Pend-a-Flex folders, or going through an electronic record on computer software with your staff, the patient record is one of the most crucial pieces of documentation to be reviewed during survey.

Maintaining a complete, accurate, and well-organized patient record will help you get through survey successfully. The documentation demonstrates for the surveyor that you are holding up your end of the bargain in terms of caring for a patient/customer. More importantly, these records ensure your organization can operate efficiently and smoothly, submit accurate and legal bills to payer sources, and even reduce exposure to lawsuits.

So, what is a surveyor looking for when they comb through the patient record? Documentation of legal and appropriate billing processes are reviewed to evaluate your compliance. Additionally, clinical and care planning notes are reviewed to ensure that you’ve educated and cared for the patient per standards, law & regulation, and best practices. Depending on the type of equipment and services the patient/customer is receiving, you can expect the surveyor to review for the following bits of information:

• Complete demographic information for the patient/customer along with a description of equipment and services received and the date of delivery (PS 6)
• Verification of receipt of the equipment/services and all appropriate paperwork (PS 6)
• Current and complete physician prescription (PS 2)
• Certificate of Medical Necessity, if applicable (PS 2, PS 3)
• Medical documentation of need including physician notes, Face to Face documentation, etc., if applicable (PS 2, BC 2)
• Patient education materials and verification of patient receipt of these materials (PS 6)
• Patient acknowledgement of financial responsibility (BC 2, PS 6)
• Patient acknowledgement of receipt of rights & responsibilities, Privacy Practice policies, after hours instructions, and warranty information (PS 4, PS 5, PS 6)
• Patient instruction regarding filing complaints to the organization and/or accrediting body (PS 6, PS 8)
• Patient receipt of Medicare Supplier Standards (or statement with hyperlink to access the Standards) (ORG 2)
• A plan of care (PS 3)
• Home safety assessment, if applicable (DEL 4, PS 4, PS 6)

In addition to these bits of information, the surveyor will assess the overall organization of the record. Are they able to locate the information in the file? Is the organization consistent in how they organize the files? Are the required documents and any other documentation complete, signed, and dated? For written records, does the organization document in pen (as opposed to pencil), and avoid the use of correction fluid within the file? For electronic records, are the records secured with password protection?

Think of the patient record as a legal document that could be called into court. Would your organization be able to defend its practices and procedures by submitting the patient record for review by a court or regulatory authority?

Patient records are the written documentation of the care we provide to our patient/customers. Absent good documentation, there is no way to evidence that a piece of equipment was delivered, or that care and service were provided.