Patient medical records are used by sleep facility personnel to monitor and document the plan of care for each patient.

These important documents contain vital information that fosters continuity in care, minimizes the risk of errors, and helps personnel identify areas of concern so they can make adjustments to improve quality of care and outcomes. In addition, payors rely on medical records to validate provision of care/services for reimbursement.

ACHC Sleep Accreditation Standards specify content requirements for patient medical records.

Standard SLC5-1A: Written policies and procedures are established and implemented relating to the required content of records for clients/patients who have received sleep testing either in the home or facility setting. An accurate record is maintained for each client/patient.

ACHC specifies that required content includes but is not limited to:

• Referral (care/service order form and face-to-face physician notes)
• Patient demographics, including insurance information
• Emergency contact information
• Epworth score
• Patient information sheet, including current medications
• Pre-sleep questionnaire
• Post-sleep questionnaire
• Sleep notes from the technician conducting the study
• Scoring report
• Final report with physician interpretation
• Type of device used for a home sleep study (HST), if applicable
• HST education documentation
• Consent for care
• Documentation of receipt of the Patient Rights and Responsibilities statement
• Financial disclosure

All documentation of care/services provided should be dated and signed with full legal signatures and credentials.

Sleep labs/centers are encouraged to conduct regular self-audits of patient records to ensure required content is included.

Here to Help

ACHC is more than an accreditor. We are your partner. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242, ext. 457.