Run Transition of Care Documentation Audit — Free

Audit Scope and Transition Type

Receiving setting identified critical (required)

Audit date and record reviewed

Note (optional)

Discharge/transfer date documented critical (required)

Core Transition Documentation

Discharge summary completed and available before transfer critical (required)

Yes No N/A

Reason for transfer and current clinical status documented critical (required)

Yes No N/A

Active diagnoses and problem list included critical (required)

Yes No N/A

Medication reconciliation completed with discharge medication list critical (required)

Yes No N/A

Allergies and adverse reactions documented critical (required)

Yes No N/A

Pending tests, results, and follow-up actions documented

Yes No N/A

Note (optional)

Handoff Communication and Transmission

Receiving provider or facility identified by name critical (required)

Yes No N/A

Handoff communication completed and documented critical (required)

Verify that the handoff included the clinical status, care needs, and any time-sensitive concerns.

Yes No N/A

Discharge packet or transfer record transmitted successfully critical (required)

Yes No N/A

Receiving party acknowledgment documented when required

Yes No N/A

Note (optional)

Service-Specific Requirements

Home health face-to-face encounter documented when applicable

Yes No N/A

Note (optional)

SNF transfer includes functional status and care needs

Yes No N/A

Note (optional)

Hospice transfer includes goals of care and symptom management plan

Yes No N/A

Note (optional)

Patient Instructions and Closeout

Patient and caregiver instructions documented critical (required)

Yes No N/A

Follow-up appointments and contact information provided critical (required)

Yes No N/A

Red-flag symptoms and escalation instructions included critical (required)

Yes No N/A

Corrective actions or documentation gaps recorded

Yes No N/A

Note (optional)

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Run: Transition of Care Documentation Audit

Audit Scope and Transition Type

Core Transition Documentation

Handoff Communication and Transmission

Service-Specific Requirements

Patient Instructions and Closeout

Get your results