Transition of Care Documentation Audit

Audit template to verify completeness and handoff readiness of transition-of-care documentation for patients discharged to SNF, home health, or hospice.

Audit Scope and Transition Type

• Receiving setting identified
• Audit date and record reviewed
• Discharge/transfer date documented

Core Transition Documentation

• Discharge summary completed and available before transfer
• Reason for transfer and current clinical status documented
• Active diagnoses and problem list included
• Medication reconciliation completed with discharge medication list
• Allergies and adverse reactions documented
• Pending tests, results, and follow-up actions documented

Handoff Communication and Transmission

• Receiving provider or facility identified by name
• Handoff communication completed and documented
  Verify that the handoff included the clinical status, care needs, and any time-sensitive concerns.
• Discharge packet or transfer record transmitted successfully
• Receiving party acknowledgment documented when required

Service-Specific Requirements

• Home health face-to-face encounter documented when applicable
• SNF transfer includes functional status and care needs
• Hospice transfer includes goals of care and symptom management plan

Patient Instructions and Closeout

• Patient and caregiver instructions documented
• Follow-up appointments and contact information provided
• Red-flag symptoms and escalation instructions included
• Corrective actions or documentation gaps recorded