Maintaining accurate records for your sleep patients is essential to ensuring the provision of quality care.

ACHC Sleep Accreditation Standards require patient records be kept up to date for in-lab and home testing services (HST). Standards also require that certain items, including completed pre- and post-testing patient questionnaires, be included in each record.

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.

Records for in-lab and HST testing services should contain all required information, including completed questionnaires.

Common Deficiency

During an accreditation survey, many sleep facilities often are cited for not having both pre- and post-sleep testing questionnaires completed and documented in patient records.

The latest Quality Review edition of The Surveyor newsletter found that Standard SLC5-1A was the most frequently cited deficiency, with 50% of those surveyed not meeting standard requirements.

HST Patients

Ensuring patients complete both questionnaires is especially important for HST patients.

The home testing environment, while convenient for patients, doesn’t support face-to-face interactions.

Questionnaires are an efficient way to document conditions in the home, providing critical insights about patient pre- and post-testing activities/conditions that can aid sleep physicians and technicians.

Tips for Compliance

• Review standard requirements for client/patient records. The standard lists minimum information that must be included in each record. Create checklists that cover all areas of required documentation for reference by staff.
• Re-educate staff on the importance and expectation for timely, complete, comprehensive documentation of pre- and post-testing evaluations, equipment used, and other information.
• Audit patient records for completeness.

Here for You

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. 458.