Internal UR Minutes from:

(Agency Name/Program)

(Month/Year)

name of Reviewer & tITLE	Client I.D.#	Med NecesS Y/N	dx con Y/N	icd-10 code used y/n	CLient/ caReGiVer sIGNature ON PLAN Y/N	COORD OF CARE Y/N	MISSING PROGRESS NOTES Y/N	NARRATIVE CORRECTIVE ACTIONS (MCFLOOPS) Include letter and number from MCFLOOPS