Medical Review Resources
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Annual Medical Review
What documentation is needed?
Documentation within the past 12 months should include:
- Any primary and/or specialty provider records/orders within the past 12 months and the following health records as applicable
- Age-appropriate exams
- Labs
- Dietary and nutrition orders
- Hospital/ER records
- Therapy/treatment records and orders
- Nursing orders
- Person-Centered Support Plan
- Information related to the individual’s involvement and schedule of meaningful day activities provided outside of the residence.
- A copy of the behavioral plan (if applicable) and data being collected on the behavioral plan as well as documentation of any reactive strategies implemented involving the client.
Documentation within the past 30 days should include:
- Medication administration record and medication error reports