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Engage non-clinical staff in ongoing records review

HIM Connection, April 1, 2003

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Dear Colleagues:

Regardless of how your facility conducts its ongoing review of medical records--whether by using an existing committee, a team created specifically for ongoing records review, or a combination--the physicians, nurses and other clinical staff involved can spare only a limited amount of time for review activities.

Consider including some non-clinical staff as part of the multidisciplinary ongoing records review team. Although the Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards no longer identify administrators as required ongoing records review participants, it can be beneficial to include the HIM department administrator as a team member.

Strategically, it is important for this individual to understand and support the review process. Representatives from the admitting, utilization review, performance improvement, HIM, and IS departments can be useful members of the team as well.

Support staff, including coders or analysis personnel, can perform baseline studies at discharge to determine where documentation problems may exist and areas where the ongoing records review team might conduct focused reviews. For concurrent reviews, HIM staff can provide review forms, help to identify samples of records, and collate the data once the review is done.

Since the JCAHO continues to include the closed medical record review session as part of its survey process, the more individuals a facility gets involved and committed to the ongoing records review process, the better. When it comes time for survey, the facility will have its review team prepared to participate in the closed record review session.

Equally important as selecting ongoing records review team members is orienting and training the team. Require team members to attend orientation and training, but make it fun. Consider serving food and awarding a certificate of completion to team members who demonstrate an understanding of the ongoing records review process. Provide team members with a full description of the review process and outline clearly the expectations for attendance and for meeting the goals of ongoing records review.

This week's HIM Connection was adapted from an excerpt of Ongoing Records Review: A Guide to JCAHO Compliance and Best Practice, by Jean S. Clark, RHIA. This new, second edition 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. Click here for more information or to order your copy.

Sincerely,

Laura Motta
Editorial Assistant
lmotta@hcpro.com

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