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Minimum Record Review Outpatient Physical Therapy (OPT)

QUAD A’s OPT program was previously approved by CMS to conduct a clinical record review of 20 records. However, we are updating our clinical record review for re-surveys from 20 to 25 clinical records to be in alignment with the guidance to state agency surveyors that is published in the SOM Appendix E - Guidance to Surveyors: Outpatient Physical Therapy or Speech Pathology Services (cms.gov) page 33:

§485.721 Condition of Participation: Clinical Records 
Sample a minimum of 25 clinical records, representing both the organization’s current roster of patients, as well as records from discharged patients, from the past six months. The sample must include records from both the primary site and any extension locations. Include in the sample those patients whose treatment are/were provided by a contracted employee, to ascertain whether evaluations, plans of care, progress notes, and other pertinent clinical material are present and that the clinical records for all patients are maintained on the premises of any location at which services are rendered. 

For Outpatient Physical Therapy facilities seeking initial accreditation, surveyors will continue to review ten (10) clinical records.

If you have any further questions, please feel free to submit them to standards@quada.org

Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.