Documentation Audit Tool for Pulmonary 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.
Pulmonary Rehabilitation Program Requirements
Requirement |
Detail |
Yes |
No |
---|
Physician referral to admit to pulmonary rehabilitation program | | | |
Patient has moderate to very severe COPD; GOLD Classification II, III or IV; OR patient has confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks | | | |
Supervising physician is immediately available and accessible for medical consultations and emergencies at all times or direct supervision if office based | -
Documentation to support physician availability (hospital based) or direct supervision (office based), e.g. physician daily log. -
Direct supervision must be furnished by a doctor of medicine or osteopathy; non-physician practitioner cannot provide supervision.
| | |
Individualized treatment plan | -
Physician signed prior to or on start date of treatment sessions; then physician reviewed and signed every 30 days. -
The plan must indicate the type, amount, frequency and duration of PR items and services. -
Must include measurable and expected outcomes and estimated timetables to achieve these outcomes.
| | |
Physician prescribed exercise program | -
Aerobic exercise must be included in each PR session. -
Target intensity (e.g., a specified percentage of the maximum predicted heart rate or number of METs). -
Duration of each session (e.g., "20 minutes"). -
Frequency (number of sessions per week).
| | |
Patient education and training | -
Documentation of education and training that assists patient in achievement of individual goals toward independence in activities of daily living, adaptations to limitations and improved quality of life. -
Must include information on respiratory problem management and, if appropriate, brief smoking cessation counseling.
| | |
Psychosocial assessment | -
Written evaluation of patient’s mental and emotional functioning relating to the patient’s rehabilitation or respiratory condition. -
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 | | | |
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