Documentation Audit Tool for Cardiac Rehabilitation Program Requirements
By Nina Youngstrom
This tool was developed by Georgia Rackley, a senior clinical specialist at SunStone Consulting. Cardiac and pulmonary rehab are on the approved list of audit targets of recovery audit contractors. Contact her at georgiarackley@sunstoneconsulting.com.
Cardiac Rehabilitation Program Requirements
Requirement |
Detail |
Yes |
No |
---|
Physician referral to admit to cardiac rehabilitation program | | | |
-
Acute myocardial infarction within the preceding 12 months -
Coronary artery bypass surgery -
Current stable angina pectoris -
Heart valve repair or replacement -
Percutaneous transluminal coronary angioplasty or coronary stenting -
Heart or heart-lung transplant -
Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks
| | | |
Supervising physician is immediately available and accessible for medical consultations and emergencies at all times or direct supervision if office based | | | |
Individualized Treatment Plan | -
Description of patient diagnosis. -
Physician signed prior to or on start date of treatment sessions; then physician reviewed and signed every 30 days. -
Must indicate the type, amount, frequency and duration of CR items and services. -
Must include patient specific goals for treatment.
| | |
Physician prescribed exercise program | | | |
Cardiac risk factor modification, including education, counseling and behavioral intervention, tailored to the individual’s needs | | | |
Psychosocial assessment | -
Written evaluation of patient’s mental and emotional functioning relating to the patient’s rehabilitation. -
Includes family and home situation that may affect the individual’s rehabilitation treatment. -
Psychosocial evaluation of the individual’s response to and rate of progress under the treatment plan.
| | |
Outcomes assessment of patient’s progress | -
Beginning and end evaluations based on patient centered outcomes conducted by the physician or staff at start and end of program. -
Should include objective clinical measures of exercise performance and self-reported measures of exertion and behavior.
| | |
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