Annual Program Evaluation and 90-Day Client Record Review

In short

• Every 90 days a review team checks a sample of active and closed patient records from every service, including services given under contract.
• Once a year the Agency evaluates its whole operation: policies, administration, and data on patients, visits, outcomes, staffing, referrals not accepted and discharges.
• If a review finds a gap in your documentation, fix it with a dated late entry. Never back-date.
• Reviewers never review the record of a patient they cared for themselves (Agency standard).
• Original records are reviewed at the office. Any record removed for a review is signed out and must be back within five working days.