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Hospital Documentation Report Card - Cal-PM

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Record data on the quality and type of hospital documentation associated with a client's Treatment Authorization Request file.

Prerequisite:

  1. Go to: Avatar PM > Client Management > TAR
  2. In the Select TAR field, select the Treatment Authorization Requests that have been processed for the selected episode.
  3. In the Aftercare Included? field, select whether or not the patient received aftercare.
  4. In the Physician's inpatient Admission note meets all criteria? field, select whether or not the physician's note is complete.
  5. In the Daily inpatient physician notes included? field, select whether or not physician notes were included with this TAR.
  6. In the Daily inpatient nurse notes included? field, select whether or not nurse notes were included with this TAR.
  7. In the Social worker/placement documentation (if Admin)? field, select whether or not there is any such documentation associated with this TAR.
  8. In the Legibility of inpatient notes acceptable? field, select whether or not the associated notes are legible.
  9. In the How many days does physician repeat the same note? field, enter the number of days for which the physician entered the same information.
  10. In the Overall documentation quality field, select whether the documentation quality is mostly positive, negative, or neutral.
  11. In the Documentation Review Comments field, enter any additional comments regarding the documentation.
  12. Select Submit.