Learn how to win over the JCAHO with complete and neat records

"They felt we provide good quality care, but we need to do better on documentation as an organization," says pharmacy director Karen Nordstrom, RPh.

Although the records were difficult for surveyors to read, they were somewhat sympathetic to the hospital because it is in the process of converting to a new electronic records system, Nordstrom says.

Get your charts in order

Surveyors could not always read handwriting, and they noticed missing information in some records, often because portions were already filed in the new electronic system, Nordstrom says.

"Because they focused on one patient and examined that record more closely, the discrepancies were more obvious," Nordstrom says. "That theme pervaded our visit."

Tip: Take time at the beginning of surveys to ensure that surveyors understand how to navigate the medical records. When surveyors were unable to find information, they called nurses to clarify the charts, often taking nurses away from patient care responsibilities.

The medical records director and nurses working with information technology could show surveyors how to read records and locate information because these employees are familiar with the electronic medical records as well as which parts are still on paper, Nordstrom says.

Document the reason

Surveyors told Northwestern to clean up its policy for pro re nata (PRN), or "as needed," drugs. Patient charts that included PRN drugs did not always include the reason why the patient might need the medication.

Nordstrom says this information is important if a physician prescribes "Tylenol as needed," for example, because the drug treats both pain and fever. "We weren't consistent in saying why it's needed," says Nordstrom.