Health Information Management

Important decisions and activities for ongoing records review

HIM Connection, January 28, 2003

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Dear Colleagues:

In planning an ongoing records review program, your facility must make the following decisions:

  • How often to carry out ongoing records review (i.e., weekly, monthly, as issues arise)
  • Which individuals serve on the group responsible for ongoing records review
  • How to identify performance improvement opportunities
  • Who will gather ongoing records review data and how they will do it (an individual or group usually gathers and summarizes ongoing records review data for the group responsible for the ongoing medical records review program
  • How to gather representative samples of medical records for reviews
  • Which items, or criteria, to review in each medical record
  • How, how often, and to whom to present the ongoing records review findings
  • How the facility documents its ongoing records review activities, actions, and improvements for JCAHO survey purposes.

Facilities must also coordinate the above decisions with the planning and execution of the following activities:

  • Training individuals responsible for ongoing record reviews
  • Gathering representative samples of medical records for reviews
  • Analyzing items in medical records against the established records review criteria
  • Presenting data to the group responsible for oversight of ongoing records review (medical records committee, PI committee, etc.)
  • Reporting ongoing records review-related findings to appropriate individuals, committees, departments, and other groups
  • Planning and implementing performance improvement activities to improve medical records documentation, based upon ongoing records review findings
  • Documenting actions and improvements related to ongoing records review.

The JCAHO provides minimal guidance on the planning and executing of ongoing records review. One of the reasons the JCAHO revised its standards was to allow facilities flexibility in developing ongoing records review programs that meet their particular organizational needs. For this reason, facilities must make the above decisions and plan the above activities themselves.

This week's HIM Connection was adapted from the book, Ongoing Records Review: A Guide to JCAHO Compliance and Best Practice, Second Edition. This best-selling book has been updated to include privacy transactions and identifier changes. The aim of Ongoing Records Review: A Guide to JCAHO Compliance and Best Practice, Second Edition is to provide a clear understanding of the revised JCAHO standards regarding ongoing records review and to give practical guidance in planning and implementing a JCAHO-compliant ongoing records review program.

Sincerely,

Kim Raines
Managing Editor



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