医疗机构合规 12 项
MDS / RAI Accuracy & Coding Audit (LTC)
此检查清单为英文版。
Audit of the resident assessment instrument process in long-term care to verify MDS accuracy, timeliness, CAA linkage, and care-plan coordination.
CMS RAI Manual42 CFR 483.20MDS 3.0
免费 PDF 或 Word · 输入邮箱即可下载。
Assessment Timeliness
- Is the admission (comprehensive) MDS completed by day 14 of admission? *
- Are quarterly and annual assessments completed within the required timeframes? *
- Is a significant change in status assessment completed within 14 days of identifying the change? *
Coding Accuracy
- Do MDS item responses match supporting documentation in the medical record for the look-back period? *
- Are Section GG functional items coded using the required interdisciplinary assessment and observation? *
- Are diagnoses coded in Section I supported by physician documentation and active in the look-back? *
CAA & Care Planning
- Are triggered Care Area Assessments (CAAs) documented with decisions to proceed to care planning? *
- Is a comprehensive, person-centered care plan developed within 7 days of the comprehensive assessment? *
- Is the RAI completed by an interdisciplinary team and signed/certified as accurate? *
Transmission & Integrity
- Are MDS assessments encoded and transmitted to CMS (iQIES) within required timeframes? *
- Is there a process to correct and re-transmit MDS records identified with errors? *
- Are validation reports reviewed to confirm acceptance and identify rejected records?
下载完整的MDS / RAI Accuracy & Coding Audit (LTC)检查清单
免费获取排版清晰、便于打印的 PDF，或可编辑的 Word 文档。