Medical records audit 2026

1. Click ‘Get Form’ to open the Home Health Medical Records Audit Form in the editor.
2. Begin by entering the Auditor's Name and Title, followed by the Date at the top of the form.
3. Proceed to the Admission section. Ensure that each item is checked off as 'Yes', 'No', or 'N/A' based on your review of patient documents, such as referral sheets and physician orders.
4. For each diagnosis listed (Primary DX M1020, Secondary M1022), confirm that they are supported and sequenced correctly according to agency policies.
5. Complete the Medication Profile Sheet by ensuring all medications are documented accurately, including any changes and interactions.
6. Review OASIS Assessment Forms for completeness and ensure they are signed and dated by relevant healthcare professionals.
7. Finally, add any additional comments or recommendations in the designated section before saving your completed audit.

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