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Sample chart review report

This is a composite example showing the structure of a single-stay review. All identifiers are fictional. Every recommendation below is tied to a documentation source — the same standard we apply in live reviews.

Resident profile (de-identified)

Resident ID

Resident ST-0047 (anonymized)

Admission

03/12/2026 · Medicare Part A

Primary diagnosis (billed)

I63.9 Cerebral infarction, unspecified

PDPM clinical category

Acute neurologic (as billed on MDS)

Finding 1 — documentation gap

Issue

NTA comorbidity not captured on MDS

Documentation source

Physician H&P 03/12/2026: active COPD with chronic bronchitis, on scheduled bronchodilator; nursing notes 03/13–03/18 confirm ongoing respiratory treatment.

Missed / at-risk code

J44.9 Chronic obstructive pulmonary disease, unspecified (NTA point eligible when supported)

PDPM impact

NTA score potentially under-reported by 1 point on current MDS; case-mix component may not reflect documented complexity.

Compliance risk

MAC medical review / TPE: billed NTA may not match chart if MDS not updated to reflect supported comorbidity.

Recommended fix

Reconcile MDS Section I with physician and nursing documentation; correct if supported before claim finalization; retain source notes in ADR packet.

Finding 2 — audit-defense note

Issue

GG function scoring consistency

Documentation source

Therapy eval 03/14/2026 (GG0130 self-care scores) vs. nursing ADL documentation 03/15/2026 — mild inconsistency in eating and oral hygiene support level.

PDPM impact

PT/OT case-mix groups depend on Section GG; inconsistent scoring is a common MAC denial theme.

Compliance risk

Survey and billing alignment: state surveyors and MAC reviewers cross-check GG against nursing notes.

Recommended fix

IDT reconciliation of GG with nursing ADL charting before MDS transmission; document rationale if scores differ from prior stay.

Audit-defense language: Findings above are illustrative. Live reports cite file name, note date, and MDS item for each line. RevOptix1 surfaces documentation already in the record — it does not generate clinical assertions. Your clinical team validates every change before billing or submission.

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Composite example for demonstration only. Not a guarantee of recovery or audit outcome. audit-defense@pdpmauditgroup.com