Health Information Management

TJC quarterly update: Recommendations for Improvement down, but medical record still important during surveys

HIM-HIPAA Insider, December 29, 2014

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RC.01.01.01, Content of the Medical Record, did not top the list of the survey findings for hospitals in the first half of 2014, according to the September 2014 issue of Joint Commission Perspectives. Nor was it on the list for critical access hospitals at all. However, 49% of hospitals surveyed received a requirement for improvement for this standard, primarily in the EPs related to timing and dating entries. This indicates hospitals are still using a lot of paper records. That said, the downward swing is encouraging as more and more hospitals fully implement the EMR.

 
The medical record continues to play an important part in surveys, and accurate, complete, and timely medical records will only help your survey. Continue to monitor the ability of workforce members at the point of care to locate information in the EMR during surveys. Regularly monitor the following EMR components, and make them part of your regular tracers and chart reviews:
  • Correct information in the correct medical record, especially the EMR
  • Care plans
  • History and physical reports and updates
  • Pre- and post-anesthesia evaluations
  • Operative/procedure reports
  • Postoperative progress notes
  • Restraints
  • Assessments and reassessments
 
Continue reading "TJC quarterly update: Recommendations for Improvement down, but medical record still important during surveys" on the HCPro website. Subscribers to Medical Records Briefing have free access to this article in the January issue.



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