Writing your CAH Annual Report – Three Steps for Success

The Conditions of Participation for Critical Access Hospitals, §485.641 require CAHs to complete an annual evaluation of its program. §485.641(a)(2) states, “The purpose of the evaluation is to determine whether the utilization of services was appropriate, the established policies were followed, and any changes are needed”. The evaluation must include:

  • §485.641(a)(1)(i): The utilization of CAH services, including at least the number of patients served and the volume of services.
  • §485.641(a)(1)(ii): A representative sample of both active and closed clinical records defined in the Interpretative Guidelines as: “A representative sample of both active and closed clinical records” means not less than 10 percent of both active and closed patient records”.
  • §485.641(a)(1)(iii): The CAH’s health care policies

Step 1: Develop an Outline
Before you start, develop an outline of what will be included in the report. An example is included.

Step 2: Assign Responsibilities
For each section of the report assign responsibility for gathering data/information as well as a deadline for completion. The more specific you are in what you expect – the more likely you will get the information you need.

Step 3: Present to the Medical Staff and Governing Board
The annual report should be an opportunity to not just provide information but also to generate discussion about both current services and what services might be of benefit to your community. Schedule enough time for discussion. The report is typically presented by the CEO.


1. Executive Summary

  • Does the CAH program continue to meet the needs of the hospital and community?
  • Were any new services added or present services changed?
  • Has the scope of care changed?
  • What improvements have been made in the last year?
  • Are there any new services recommended for the next year?

2. Volume and Utilization

  • Payor Mix
  • Volume by patient type
  • Volume by service
  • Transfers
  • Average Length of Stay
  • Number and/or percent of patients with an inpatient stay of more than 96 hours

3. Audit of active and closed medical records

  • Physician documentation audits (H&P, Discharge Summary, Verbal Orders, Legibility, etc.)
  • Number of internal and external professional practice reviews
  • Other audits (Blood utilization, Medication Errors, etc.)

4. Health Care Policies

  • P&P review by department
  • Summary of changes to current policies
  • New policies developed
  • Process for review and approval

5. Evaluation of Services/Quality Assurance

  • Review of contract services
  • Hospital-wide quality indicators
  • Hospital-wide improvement projects
  • External reporting (MBQIP, etc.)
  • Patient Satisfaction

6. Infection Control

  • Nosocomial Infections
  • Current year goals and results
  • Next year goals

7. Department Reports

  • Description/Scope including any new services or modalities
  • Volume/Activity
  • Satisfaction data
  • Departmental Indicator(s) and data (results)

Author: Carolyn St.Charles, RN, BSN, MBA, Regional Chief Clinical Officer

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