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TOPIC: Use record review to keep medical records accurate, complete, and timely

HIM Connection, September 16, 2003

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The ongoing records review requirements for 2004 (IM.6.10 EP 11) provide flexibility for the individual facility in developing a systematic and effective approach to identifying opportunities for improvement related to the medical record. Since the medical record serves as the foundation for patient care and safety, it only makes sense that we make sure it is accurate, complete, and timely.

The new element of performance provides a lot to consider. And, it is prescriptive in some ways and not in others. It is clear that organizations must have an ongoing reveiw process at the point of care. The organization can define its own indicators, but they must address the following points:

--Presence of data and information--Is the required data available? For example, is the history and physical (H&P) on the paper record or available electronically?

Timeliness--Are documents available according to standards, organization policy, state or federal laws? Is care provided to the patient in the most beneficial and necessary time? For example, is the H&P report on the chart or available electroically within 24 hours of admission to the hospital?

--Readability--Are the entries legible and easy to read? For example, is the handwritten H&P legible and understandable? Are copies of reports legible and free of obstructive marks?

--Quality--Does the documentation reflect an accurate picture of the care and treatment provided? Is it meaningful and appropriate to the encounter? For example, does the H&P contain all the items as required by hospital policy and additional information relevant to the condition for which the patient is being treated?

--Consistency--Does the medical record consistently reflect good standards of documentation practices and principles? Are the forms or computer screens standardized? For example, all paper forms are required to have the patient label in the top, right hand corner and the name of the organization in the top left. All forms must be identified as to purpose. The menus for charting are consistent for all types of data entry.

--Clarity--Are all entries clear as to their meaning? For example, do all orders for medications contain who gave the order, who received and recorded the order, the type of medication, the dosage, and the time period to administer the medication?

--Accuracy--Are entries free from error and according to documentation guidelines? For example, are all transcribed reports free of blanks?

--Completeness--Does the medical record contain all the reports and documentation to support the treatment provided? For example, is the medical record complete according to policy and the care that was given?

--Authentification--Has the medical record been validated for correctness for both the information itself and the person who is the author or user of the information? For example, at the time of discharge, the record is analyzed for appropriate reports and signatures.

This week's HIM Connection was adapted from an excerpt of the new edition of our best-selling book, "Ongoing Record Review: A Guide to JCAHO Compliance and Best Practice, Third Edition" Go to HCMarketplace for more information or to order. Check out the Editor's Choice section below for a kit for training coders on the 2004 ICD-9-CM codes.

Sincerely,

Lauren McLeod
Executive Editor
lmcleod@hcpro.com

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