Dear Reviewer,
Enclosed is the requested documentation for the ADR: _______________to _____________
 To show progress we have also included medical record documentation for this
patient for the following dates of service: ________________ to ________________
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

The Table of Contents below is how we have organized the Audit chart for your review
Each section has a title page followed by the specific documentation for that section
Electronic Medical Records is our primary record system except for the outcome tools
used pre and post program and the Individualized Treatment Plan (ITP)
o The education sessions are electronic and prints out in multiple pages. I
apologize for this print out and know that we are diligently working with our
EPIC IT to correct the print problem.
 We have circled and highlighted the education that
o The exercise sessions are electronic and prints out in multiple pages. I apologize
for the numerous pages that print out for one GO424 exercise session. We are
diligently working with our EPIC IT to print out a more efficient and detailed
electronic Medical Record from the data we enter into the computer.
 Only the 1st page of each exercise session has all required
documentation
 We have included all the exercise dates from the patient’s first day up to
the last date asked in audit.
 We have added on each page after 1st page the exercise date; PR staff
name treating patient, the name of the MD supervision and exercise start
time and end time.
Table of Contents
ADR
UB04
Face Sheet
Pulmonary Rehabilitation Staff Signature Sheet
Physician Supervision Policy
Calendar Dates for each service date of Physician Supervision in the ADR
Referral Order for Pulmonary rehabilitation
 H & P from referring MD
 Post Bronchodilator Spirometry Test
 Medication List or part of H & P
 Other pertinent medical information on patient
Table of Contents Continued page 2
Pulmonary Rehabilitation Orders
Pulmonary Rehabilitation Initial Evaluation
 Pre/post 6 minute walk test
 Pre/post muscular fitness test
 Pre/post outcome tools to include:
o All tests have written name of staff member and date the tests were reviewed
and scored.
o St. George Respiratory
o Hospital Anxiety and Depression Scale
o COPD assessment Test
o Epworth
o Knowledge Test
Outcome Summary Tool
Individualized Treatment Plan (ITP)
Education/Training Documentation – apologize for the Electronic Medical Record Print out.
We are working with our EPIC team to build a better print out of our documentation tool.
Description of all Education/Training sessions
Home Recommendations if the ADR includes this service date
Therapeutic Exercise Documentation – apologize for the Electronic Medical Record Print out.
We are working with our EPIC team to build a better print out of our documentation tool.
Thank you.
Gerilynn L. Connors, BS, RRT, MAACVPR, FAARC
Clinical Manager, Respiratory Care Outpatient Services, Pulmonary Diagnostics & Pulmonary
Rehabilitation
INOVA, Inova Fairfax Medical Campus
Falls Church, VA 22042
Tel 703 -776-3070
Fax 703-776-3082
gerilynn.connors@inova.org
 ADR
 UB04
 Face sheet
 Pulmonary Rehabilitation
Staff Signature Sheet
 Physician Supervision Policy
 Calendar Dates for each
service date of Physician
Supervision in the ADR
Referral Order for Pulmonary
Rehabilitation
 H & P from referring MD
 PFT’s completed within
one year of patient
starting pulmonary rehab
program
 Medication List or part of
H&P
 Other pertinent medical
information on patient
 Pulmonary Rehabilitation
Orders
Pulmonary Rehabilitation
Initial Evaluation
 Pre/post 6 minute walk test
 Pre/post muscular fitness
test
 Pre/post outcome tools
o All tests have written name of staff
member and date the tests were
reviewed and scored.
o St. George Respiratory
o Hospital Anxiety and Depression Scale
o COPD assessment Test
o Epworth
o Knowledge Test
 Outcome Summary Tool
 Individualized Treatment
Plan (ITP)
Education/Training
Documentation apologize for the
,
Electronic Medical Record Print out. We are
working with our EPIC team to build a better print
out of our documentation tool
 Description of all
Education/Training sessions
 ADR education/training
dates
 Home Recommendations
o if the ADR includes this
service date
Therapeutic Exercise
Documentation , apologize for the
Electronic Medical Record Print out. We are
working with our EPIC team to build a better print
out of our documentation tool
 ADR Therapeutic Exercise
dates