5.19 – Audit of Medical Services

Open Door will maintain medical records and documentation for each individual served as outlined in the individual’s plan.  Medical documentation includes, but is not limited to (can be written or through electronic documentation systems):

• Admission records
• Annual History and Physicals
• Medical care plan for all individuals
• Individual health exam/reviews
• Comprehensive medical consults, including referral and coordination with all specialists
• Medication and treatment orders, including necessary labs and tests
• Progress notes
• Hospital visits/Emergency room visits
• Medical assessments
• Incident logs: seizure, falls, bowel tracking, etc…
• Immunization record
• Medication Administration records

For ICF, Medical documentation and services will be audited to ensure quality of care.  During the audit by QI nurse assigned, the following will be thoroughly reviewed and completed monthly:

• Physician order Audit
• Medication Administration Record Audit-accuracy of orders, documentation completion
• Medication Pass Observation Audit 
• Chart Audit
• Medical appointment audit

Results of the audits will be routed for follow-up including staff training, administration of disciplinary action as per 2.15, and or any other recommendation of QI team.  Audits may be reviewed by team randomly.

For Waiver settings, records are maintained at the service location and in the Corporate office files.  The Case Manager is responsible for on-going monitoring of services including completion of location audits at least twice per year including medical documentation, follow-up and review.

Last Revised: 6/6/22