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The Joint Commission Back to Closed Record Review?

Accreditation Monthly, November 12, 2009

Have you heard that the Joint Commission survey will again be doing closed record review? For hospitals with deemed status, CMS is requesting The Joint Commission to review records at a rate of 10% of the average daily census or a minimum of 30 records (20 for small hospitals) during the survey process. If The Joint Commission does not review the required number of records during the open record tracer review, the surveyors will ask to review additional open and closed records. We've already had two clients that have had this happen.

What does this mean for you? You can expect that Joint Commission surveyors will pretty much sit in a room (from what the clients say) and review the records. This gives them more opportunities to find RFIs. Some of the additional vulnerabilities of reviewing the closed record include:

• Review of the appropriateness of the discharge summary
• Discharge teaching
• Unmet goals from the care plan are addressed at discharge
• Medication reconciliation at discharge (although not scored this year)
• Authentication of verbal/telephone orders within 48 hours (or state statute requirement)
• Completeness of the medical record

The Joint Commission is not moving away from the tracer method—it is committed to that survey process—it simply has to meet the required number of records as stipulated by CMS.

We will wait and see how this affects the survey findings in the months to come!

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