Evaluation reviewed? (Total Points Available =40)

Medical Diagnosis supported by Reason for Referral (3 Points= Yes)                                                                                        

Comments regarding Medical Diagnosis 

Treatment Diagnosis supported by Functional Deficit Areas (3 Points= Yes)                                                                             

Comments regarding Treatment Diagnosis 

Evaluation Procedure Code checked on Evaluation (1 Point= Yes)                                                                                                   

POC modifications addressed only by Clinician (3 Points= Yes)                                                                                                                   

Standardized Assessment(s) in Evaluation, with correlation to Functional Deficit Areas (5 Points= Yes)              

Statement of Functional Interpretation for Standardized Assessment(s) (5 Points= Yes)                                       

Caregiver Training Goal (5 Points= Yes)                                                                                                                                   

Discharge Program addressed in Evaluation (5 Points= Yes)                                                                                                        

Is the POC/signed/dated/credentialed within 30 days or addressed through Delayed Certification?(10 Points= Yes)                                  Comments regarding Evaluation 

UPOC reviewed? (Total Points Available =20)

Is UPOC completed per prescribed duration, signed/dated/credentialed within 30 days, or addressed     

through Delayed Certification? (10 Points= Yes)                                                                                                                                    

UPOC updated with Standardized Testing with Functional Interpretation (5 Points= Yes)                                           

UPOC updated with Caregiver Training Goal (5 Points= Yes)                                                                                                                         

Comments regarding UPOC 

Progress Notes reviewed? (Total Points Available =10)

Progress Notes reflective of skilled intervention with barriers/modifications noted (4 Points= Yes)  

Caregiver Training documented in Progress Note (3 Points= Yes)                                                              

Progress Note authored/credentialed by Clinician (3 Points= Yes)                                                            

Comments regarding Progress Notes 

Daily Notes reviewed? (Total Points Available =20)

Daily Notes support Procedure Code(s) billed (3 Points= Yes)                                                                                                 

Daily Notes reflect services distributed across Procedure Code(s) prescribed in POC/UPOC (3 Points= Yes)    

Daily Notes demonstrate collaboration between Clinician and Assistant (3 Points= Yes)                              

Daily Notes credentialed by author (1 Point= Yes)              

Daily Notes support skilled intervention provided (5 Points= Yes)                                                                        

Daily Notes specify Caregiver Training with Return Demonstration 1 x week (5 Points= Yes)       

Comments regarding Daily Notes 

Discharge Summary reviewed? (Total Points Available =10)

Discharge Summary supports length of stay (4 Points= Yes)                                                                                                 

Discharge Summary updates Standardized Testing (2 Points= Yes)                                                                          

Discharge Summary summarizes Caregiver Training with Return Demonstration (2 Points= Yes)     

Discharge Summary includes discharge instructions (1 Point= Yes)                                                                             

Discharge Summary identifies prescribed follow-up program (1 Point= Yes)            

Comments for Discharge Summary