Acute Care Hospitals
Documentation Survey Readiness — Starter
A tracer-style documentation review of 10 patient charts from one hospital-selected unit or floor, following each patient through documented handoffs and transfers.
$8,950 — 10 charts, one unit or floor
Pay NowA tracer-style documentation review of 10 patient charts from one hospital-selected unit or floor, following each patient through documented handoffs and transfers.
At a glance
Who it's for
- Hospital risk managers and compliance leaders
- Clinical, quality and patient safety teams
- Hospital leadership and counsel
What you receive
- Tracer-style review of 10 charts from one hospital-selected unit or floor
- Documented patient pathways reconstructed across units, handoffs, transfers and discharge
- Record-supported findings flagged against applicable accreditation, CMS and state requirements
- Balanced findings, documentation priorities and a fix-first list
- A one-page staff huddle sheet
- A 45-minute leadership debrief on Zoom
What is not included
- Direct observation of care or onsite survey activities
- Staff or patient interviews
- Whole-hospital readiness or a mock survey
- Certification of compliance or a promise of passing a survey
Hospital-experienced review team
Before the engagement is accepted, Michelle confirms that at least one assigned analyst or specialist has recent acute care experience relevant to the selected unit. Applicable standards and the current Hospital Survey Process Guide are mapped to record-checkable evidence before review begins.
Scope and record limits
Scope
Through The Lexcura Clinical Intelligence Model™, we trace each selected patient’s documented pathway across every hospital unit they touched, with particular attention to handoffs, transfers and discharge. Findings identify strengths, concerns, unfavorable evidence and gaps against applicable requirements within the 2026 Joint Commission’s 14 National Performance Goals, CMS Conditions of Participation and your state’s requirements. Only evidence available in the agreed records is assessed; chart review alone cannot establish that an organizational goal or standard is met.
Record limits
10 patient charts selected from one unit or floor chosen by the hospital — such as ED, ICU or med-surg. Those 10 patients are followed through their documented care across other units; this does not add ten new patients at each transfer. The selected unit, complete patient pathways, admission/date ranges and included page allowance are agreed in writing. Additional pages are $350 per 100, separately invoiced and paid before review begins. No whole-hospital review is included.
Every Lexcura review is balanced. Your report names the strengths in your documentation alongside the concerns — including unfavorable evidence and gaps — so you see the record the way an attorney, an auditor or a surveyor would.
Reviews are measured against applicable CMS Conditions of Participation, Joint Commission standards and state licensure rules, alongside your own policies. Each regulatory overlay is state specific: your hospital is measured against its own state's rules — Florida requirements for Florida hospitals, and each other state's requirements for hospitals in that state.
Reviews can be requested through hospital counsel or your patient safety process. Counsel should determine the appropriate structure and protections before records are shared; requesting a review does not itself establish attorney-client privilege or patient safety work product protection.
What we check in the charts
The Starter review follows the same ten patients through their documented hospital pathways. These checks apply to the care and services relevant to those charts—not every service in the hospital.
Goal numbers and brief labels follow the Joint Commission’s 2026 National Performance Goals. The categories below describe Lexcura’s record-review scope; they are not Joint Commission coverage ratings.
Core chart checks
Goal 1 — Right Patient, Right Care
- Recorded patient identifiers associated with medication, laboratory and blood-product documentation.
- Critical-result reporting and documented response times; vital-sign trends, recognition of deterioration, escalation and rapid-response notes.
- Transfer and handoff documentation across the selected patient’s pathway, including discharge.
Limit: Records cannot verify bedside identification, actual alarm settings or hospital-wide patient-flow performance.
Goal 6 — Pain Management
- Documented pain assessment and reassessment after treatment.
- Opioid orders, sedation monitoring, multimodal plans and patient education, where applicable.
Limit: Records cannot establish hospital-wide prescribing performance or confirm unrecorded monitoring.
Goal 7 — Safe Informed Care
- Consent documentation, signatures and timing before a procedure.
- Recorded discussion of risks and options, language needs and interpreter support.
Limit: A signed form does not establish that the patient understood the conversation or that consent requirements were fully met.
Goal 8 — Reducing the Risk for Suicide
- Applicable screening and follow-up risk assessments.
- Ordered observation levels and documented checks; safety planning and discharge follow-up, where applicable.
Limit: No onsite ligature-risk assessment, observation of safety practices or confirmation of checks beyond the documentation.
Goal 14 — Effectively Managing Medications
- Medication orders and reconciliation at admission, transfers and discharge.
- Administration records compared with orders; documented high-alert medication monitoring and adverse drug events.
Limit: Pharmacy storage, dispensing systems and actual administration practices are not assessed onsite.
Additional observations, where applicable
We flag the following evidence only when the relevant care appears in the selected records. These observations do not evaluate the hospital-wide programs behind each goal.
Goal 4 — High Quality, Safe Care for All
- Documented social-needs screening, interpreter use and referrals.
Limit: No assessment of hospital-wide disparity data, leadership responsibilities or outcome tracking.
Goal 5 — Preventing and Controlling Infection
- Recorded isolation orders and care; line and catheter necessity and care documentation; antibiotic timing and documented review.
Limit: Records cannot confirm actual precautions or hand hygiene. Infection surveillance and stewardship programs are outside this chart-only scope.
Goal 9 — Tissue Transplant Safety
- Tissue identification and tracking documented in relevant surgical records, if present in the selected charts.
Limit: No assessment of tissue storage, suppliers or hospital-wide tracking systems.
Goal 13 — Protecting Patients and Providers in Imaging
- Applicable documented pregnancy or MRI screening, contrast reactions and radiation-dose information, where recorded.
Limit: No inspection of shielding, equipment or dose-optimization programs.
Outside the Starter chart-review scope
These organizational areas need evidence beyond the ten patient charts, such as program files, interviews, observation or onsite assessment. They are not assessed for compliance in Starter.
- Goal 2 — Culture of Safety: Governing-body and leadership processes, culture surveys, incident-reporting systems and sentinel-event reviews.
- Goal 2a brief — Preventing Workplace Violence: The prevention program, workforce risk assessments and incident-reporting systems. Documented aggression or risk flags may be noted, but do not establish program compliance.
- Goal 3 — Emergency Readiness: Emergency plans, drills, community coordination and operational readiness.
- Goal 10 — Waived Testing: Testing quality-control logs and staff competency. A recorded result does not establish testing quality.
- Goal 11 — Creating a Secure and Safe Physical Environment: Fire safety, security, equipment, utilities and onsite environmental conditions.
- Goal 12 — Health Professional Resource Management: Staffing adequacy, credentials, competency files and nurse-executive responsibilities.
How findings are reported
- Each finding identifies the chart evidence and relevant goal or applicable requirement, with CMS and Florida requirements considered where applicable.
- Strengths, concerns, unfavorable evidence and gaps are distinguished, with documentation priorities and a fix-first list.
- Items are identified as reviewed, not applicable to the selected charts, unable to assess from the records, or outside scope.
- Missing documentation is reported as a documentation gap—not proof that care was omitted.
- No finding certifies hospital-wide compliance or predicts whether the hospital will pass a survey.
Timing and price
Standard delivery is 30 business days after cleared payment and complete records; rush delivery is 20 business days for an additional $1,500, subject to agreed availability. Reports go directly to you, with an optional 20-minute discussion.
$8,950, paid in full upfront. Additional pages are $350 per 100 pages; rush adds $1,500. Agreed extras are separately invoiced and paid before work begins. Card payments add 3%; bank transfers have no added processing fee.
Arrange rush availability with Michelle before purchasing this optional add-on.
Pay Now — Agreed rush delivery · $1,500How an engagement works
- 01
Conflict check and scope: Michelle confirms availability and agrees the records, date range and page allowance with you in writing.
- 02
Agreement, BAA and payment: Sign the services agreement and Business Associate Agreement. Pay the full base price upfront; any agreed overages are invoiced separately and paid before work begins.
- 03
Secure records transfer: After the agreements are signed, Michelle sends your private portal link. Sign in and upload the agreed complete records and policies there, never by email or through this website.
- 04
Review and delivery: Your written report is delivered directly to you, naming strengths, concerns, unfavorable evidence and gaps. Standard delivery is 30 business days after cleared payment and complete records; rush is 20 business days for an additional $1,500, subject to agreed availability.
How to share records
After your conflict check and cleared payment, Michelle sends the services agreement and BAA. Reviews may be requested through hospital counsel or your patient safety process; counsel should determine the appropriate protections before records are shared.
- Michelle sends you a private secure-portal link after the agreements are signed.
- Use that link to sign in and upload the complete records and agreed policies for your selected service.
- Do not upload records through this website or send patient information by email.
- The record date range, included page allowance and any $350-per-additional-100-page overage are confirmed in writing. Overage invoices must be paid before review starts.
Pay Now
Documentation Survey Readiness — Starter: The base price must be paid in full upfront. Any overage is invoiced separately and must also be paid before work begins. Submitting an inquiry does not place a paid order.
After cleared payment and a signed agreement, Michelle sends the next steps. Medical records are shared only through the secure portal after the services agreement and BAA are signed — never by email.
Larger engagements
Standard and Full documentation-readiness engagements are available on request only. Michelle confirms scope, staffing, timing and price before any commitment.
Standard
10 charts per unit, up to 3 hospital-selected units, plus 4 policies checked against documented practice. Scope and price agreed before commitment.
Available on request
Discuss StandardFull
The 30-chart hospital pilot plus an event review. Scope, page allowance, staffing, timing and price agreed before commitment.
Available on request
Discuss FullQuestions before paying
Documentation survey readiness only: findings are limited to the records provided. This is not a mock survey, an onsite patient tracer or a guarantee of survey outcomes. Records alone cannot establish undocumented actions, consistent practice or hospital-wide compliance. No billing, coding or legal advice.