Home Health & Hospice

Quarterly Clinical Record Review: Know the Requirement

Homecare Insider, May 30, 2011

Your homecare agency’s professional advisory committee (PAC) is required, by Condition of Participation (CoP) 484.52, to conduct an annual evaluation of your program. It is also required that you have written policies regarding this annual evaluation. This evaluation must consist of an overall policy and administrative review and a clinical record review. The clinical record review, which is a standard within this CoP, must be conducted at least quarterly and it must involve both active and closed charts. Those conducting the reviews are to be the appropriate professionals who represent the scope of your agency’s program.

For example, if your agency provides skilled nursing, physical therapy, and occupational therapy, a representative from each of these disciplines should conduct the chart review. The purpose of this clinical record review should be to determine whether your agency’s established policies were followed-and the adequacy of the plan of care and the appropriateness of continuation of care.

Many agencies do, and should, conduct clinical record reviews more frequently than quarterly. Either way, a summary of your agency’s clinical record reviews should be presented to the PAC during the agency’s annual evaluation. The summary should include any issues identified and trends noted during clinical reviews. It should also include actions taken by the agency to rectify or prevent those issues and trends.

 If your agency conducts more frequent clinical record reviews, you can easily summarize those on a quarterly basis to meet this requirement, which states, in part, “…at least quarterly, appropriate health professionals, representing at least the scope of the program, review a sample of both active and closed clinical records…” So, in other words, you can certainly do them more frequently, but must do them at least quarterly and ensure they are reviewed by the appropriate professionals.