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Get set! Preparing for record reviews

HIM Connection, January 28, 2003

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JCAHO's review process contains the following components:

• Ongoing reviews
• Criteria, monitors, JCAHO requirements
• Conducting the review
• Collecting the data
• Analyzing the data
• Reporting the findings
• Making recommendations
• Action plans and follow-up

The nature of record review implies a process of a continuous nature. JCAHO specifies that certain things must be done within a certain time frame, such tracking delinquent records. Otherwise, they leave it up to you.

Record reviews should be held daily, weekly, monthly, or quarterly. It is probably not feasible to review records daily or weekly. On the other hand, some feel that quarterly reviews are too infrequent, especially if the ORR process reveals deficiencies in processes that need to be addressed. So, monthly meeting may be the better alternative for your organization. While the ORR is conducted monthly, you can certainly take advantage of items your medical record staff review on a daily basis, such as dictated history and physicals, operative reports, and discharge summaries, just to mention a few. Add that information to your ORR statistics as appropriate.

Regardless of the name you use for them, you must be able to identify the criteria, monitors, or JCAHO elements that are used to determine if you meet the standards of quality documentation.

Criteria, monitors, or elements are indicators that can be used to determine if there are deficiencies in documentation or other factors that affect data quality in your medical records. These indicators can be identified by:

• the medical record staff
• the medical staff
• the nursing staff
• or administration

Some hospital departments may feel that there are deficiencies in documentation. These can be transmitted to the record review committee via their liaison. It is also important to be aware that other aspects of the facility, such as the laboratory, also undergo accreditation. Therefore, good communication between the record review committee and these other areas of the facility can help improve data quality and alleviate deficiencies.

This week's HIM Connection was adapted from the book and CD-ROM set, Automating Ongoing Records Review: New Strategies for Success. This tool was designed to be used with basic software packages like Word and Excel. This resource will help you take your paper process a step further. The end result? You'll save time and improve your productivity and consistency through automating your ORR. For more information, click here.

Sincerely,

Kim Raines
Managing Editor

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