CMS-10630 Clinical Appropriateness for Medical Record Documentatio

OMB Control Number: 0938-TBD (Expires: TBD)

Detailed Description of the Issue
Date Identified
(MM/DD/YY)
(Completed By The CMS Audit Lead)

Brief Description Of Issue
(Completed By The CMS Audit Lead)

Condition Language
(Completed By The CMS Audit Lead)

(Explain what happened)
(Remaining fields to be Completed by PACE
Organization)

Root Cause Analysis for the Issue
(Explain why it happened)

Methodology - Describe the process that was
undertaken to determine the # of individuals
(e.g. participants) impacted

# of Individuals
Impacted

Action Taken to Resolve System/ Operational
Issues

Date System/
Operational
Remediation Initiated
(MM/DD/YY)

Date System/ Operational
Remediation Completed
(MM/DD/YY)

Date Individual
Actions Taken to Resolve Negatively Impacted
Date Individual Outreach
Outreach and
Individuals Including Outreach Description and
and Remediation Completed
Remediation Initiated
Status
(MM/DD/YY)
(MM/DD/YY)

Participant
First Name

Participant Last
Name

Participant ID

If Participant Went to the
Type of Documentation Not Present
If Hospitalized, Most Recent Date of
Emergency Room, Most Recent Date in the Participant's Medical Record
Hospitalization.
(e.g. plan of Care, Progress Notes,
of Emergency Room Visit.
(MM/DD/YY)
Lab Results, etc.).
(MM/DD/YY)

Date of Visit/ Consultation/
Hospitalization/ etc.
(MM/DD/YY)

Reason the Information Was Not
Documented.

Staff Member Responsible For
Entering the Documentation into the
Medical Record.

Was the Information Lost, Deleted,
Destroyed, etc.?
(Y/N)

If Yes, Date of Incident?

Action Taken by PO to Recover Loss,
If Any?
(Y/N)

Were There Any Negative
Outcomes?
(Y/N)

If Yes, What Were the Negative
Outcomes?

{Other Data
Requested}

{Other Data
Requested}

{Other Data
Requested}