PDPM Component Capture Audit

Pre-submission inspection for validating MDS items that drive PDPM component capture, with emphasis on therapy classification, functional status, and documentation completeness before transmission.

Audit Scope and Record Identification

• Resident record identifiers match the MDS being audited
  Confirm the resident name/identifier, assessment reference date, and assessment type match the record under review.
• Assessment is identified as a pre-submission PDPM component capture audit
  Confirm this review is being completed before transmission.
• Required source documents are available for review
  Select the source documents used to validate MDS items.

PDPM-Driving Item Completeness

• Therapy-related MDS items are complete and not left blank
  Check that all therapy-driving fields required for the assessment are populated.
• Functional status items are fully captured and internally consistent
  Confirm functional items reflect the same level of assistance across related sections.
• Clinical category indicators are supported by documentation
  Verify diagnosis and clinical indicators used for classification are documented.
• Assessment items affecting reimbursement are not contradictory
  Check for conflicts between coded items and supporting notes.

Therapy and Functional Status Validation

• Therapy minutes and modalities are supported by treatment records
  Confirm therapy documentation supports the coded treatment intensity and type.
• Functional performance level is coded using the most recent and relevant documentation
  Verify the functional coding reflects the appropriate assessment window.
• Section GG or equivalent functional items are complete
  Check that all required functional items are answered.
• Therapy and nursing documentation align on assistance level and mobility status
  Confirm interdisciplinary notes do not conflict on the resident's current status.

Transmission Readiness and Correction Control

• All identified deficiencies have a documented corrective action
  Confirm each issue has an assigned fix and owner.
• No unresolved non-conformances remain in the audit packet
  Verify there are no open issues that would affect submission accuracy.
• Audit result is ready for transmission or hold
  Select the final disposition of the assessment packet.

Final Review and Sign-Off

• Inspector name and role
  Enter the name and role of the person completing the audit.
• Audit completion date and time
  Record when the audit was completed.
• Inspector attestation
  Sign to confirm the audit was completed and findings are accurate.