Policy vs. Practice: Does Your Charting Match Your Policies?

Every agency has good policies on falls, wounds, and changes in condition. The question an attorney, an auditor or a surveyor will ask is whether staff actually follow them, and the record is where they look. This review sets your written policies side by side with real documentation, so you can see where practice has drifted from policy before someone else points it out.

At a glance

Who it's for

Compliance officers and risk managers
Directors of Nursing and clinical managers
VPs of Operations and regional leaders

Policies we review

Falls and fall prevention
Wound and skin care
Change in condition and physician notification
One more of your choice (for example, medication administration, hospice symptom management, or care planning)

What you receive

A side-by-side table: what each policy requires and what the records actually show
Gaps ranked by risk, from most to least serious
Recommended policy fixes and staff training points
The report, sent directly to you, with an optional 20-minute call to talk it through

Record sample

12 patient records, three for each policy, chosen by you from patients the policy actually applies to. Each record covers 90 days of documentation around the event: about 30 days before and 60 days after. A record includes visit notes, the plan of care, physician orders, medication records, aide and therapy notes, and incident or event reports. Outside hospital records aren't included; they can be added at $350 per additional 100 pages. Every record is reviewed against its policy through the Standard of Care and Regulatory and Compliance Overlay pillars of The Lexcura Clinical Intelligence Model™.

Scope and record limits

Scope

Four written policies compared side by side with what 12 records actually show, with gaps ranked by risk and recommended fixes.

Record limits

4 policies and 12 records (three per policy), each covering 90 days of documentation around the event. Additional records at $350 per 100 pages.

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.

Timing and price

Report delivered within 30 business days after the policies and records are received, or 20 business days with rush delivery.

$5,950 for four policies and 12 records. Rush delivery in 20 business days is available for an extra $1,500. Paid in full before records are sent.

How it works

01
Submit the request form. We run a conflict check within one business day.
02
Once cleared, you sign our services agreement and Business Associate Agreement and pay through our secure payment link.
03
You share the four policies and 12 records (three per policy) through our secure portal.
04
Your report arrives within 30 business days (20 with rush), sent directly to you. If you'd like, book an optional 20-minute call to talk it through.

Pay Now

Policy vs. Practice: 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.

Questions before paying

You choose the records. Please don't include patient names or health information. Records are shared only through our secure portal after your agreement is signed. This review is a clinical analysis, not legal advice.