Healthcare Survey Report

HEALTHCARE SURVEY REPORT

Survey Identification

Facility Name:

Survey Date:    Surveyor Name(s):

Patient Information

Date of Birth:    Gender: Male Female Other

Phone:    Emergency Contact:

Insurance Information

Policy Number:    Group Number:

Medical History

Survey Areas Reviewed

Infection Control    Medication Management    Patient Rights    Documentation    Staffing

Environment of Care    Emergency Preparedness    Other:

Observations and Findings

Provide detailed findings below. Each finding should identify the observation, applicable standard or policy, assessment of risk, and recommended corrective action.

Severity: Minor Moderate Major

Immediate risk to patient safety: Yes No

Responsible Party:    Due Date:

Severity: Minor Moderate Major

Immediate risk to patient safety: Yes No

Responsible Party:    Due Date:

Evidence and Attachments

Photographs, documents or other evidence attached: Yes No

HIPAA / Privacy Acknowledgment and Authorization

By signing below, the patient or authorized representative acknowledges that protected health information relevant to this survey may be reviewed by survey personnel as necessary to document findings. This review is conducted in accordance with applicable privacy and confidentiality obligations. The undersigned authorizes release of the minimum necessary medical records related to the observations in this report.

Certification

I certify under penalty of perjury under applicable law that the information contained in this Healthcare Survey Report is true and accurate to the best of my knowledge. I understand that false statements may subject the signer to civil or criminal penalties under governing statutes. The facility and its representatives shall implement corrective actions as described above within the stated timelines or otherwise notify the survey authority in writing of alternative remedial measures.

Sign Now