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Be prepared to make crucial decisions regarding your ongoing records review

HIM Connection, March 28, 2003

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Dear Colleagues:

In planning your ongoing records review (ORR) program, you must make the following decisions, presented in no particular order (in different facilities, there may be different groups or individuals responsible for the following decisions):

• how often ORR is carried out (i.e., weekly, monthly, as issues arise);
• which individuals serve on the group responsible for ORR;
• how performance improvement opportunities are identified;
• how and by whom ongoing records review data is gathered;
• how representative samples of medical records for reviews are gathered;
• which items, or criteria, are reviewed in each medical record;
• how, how often, and to whom the ORR findings are presented; and
• how the facility documents its ORR 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 to serve on the ORR team;
• 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 ORR (medical records committee, PI committee, etc.);
• reporting ORR-related findings to appropriate individuals, committees, departments, and other groups;
• planning and implementing PI activities to improve medical records documentation, based upon ORR findings; and
• documenting actions and improvements related to ORR.

The JCAHO provides minimal guidance on the planning and execution of ongoing records review. JCAHO revised its standards in 1998 to allow facilities flexibility in developing ORR 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" by Jean S. Clark, RHIA. This book draws on the author's experiences as well as on contributions from a number of other medical records professionals. It explains the JCAHO standards, intent statements, and scoring guidelines in plain English. It also provides straightforward, step-by-step advice on how to develop a more effective, efficient ongoing records review program, including advice and strategies for achieving a high level of physician participation in your records review program. For more information, or to order your copy, click here.

Sincerely,

Kim Raines
Managing Editor

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