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Preparing for Tracer Methodology

HIM Connection, January 27, 2004

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Accurate, complete, legible, and timely medical records are essential elements for periodic performance reviews (PRR) and on-site surveys, particularly when preparing for the JCAHO's new tracer methodology. To make sure operational systems and processes based upon the actual experience of the patient are in compliance, assess their effectiveness by looking at the entire sequence of care provided to the patient. This is a better option than reviewing a few records in each department against a check-off list, like in previous surveys.

The medical record should accurately reflect the patient's care and treatment from start to finish. Late entries, poor documentation, and illegible entries can negatively affect the quality and safety of patient care.

The following three tips for ongoing chart reviews will help you focus on the important issues as you conduct your own tracer reviews:

1. For quality of documentation ask yourself the following questions:

-Does the record clearly reflect that the care and treatment provided to the patient is appropriate and completed in the beneficial and necessary time? For example, are the assessments and treatments for pain meaningful to the patient's condition?

-Is the plan of care based upon documented communication between the physician and the other caregivers or does it look fragmented? Is it truly interdisciplinary?

-Does the treatment appear to be appropriate for the diagnosis?

2. When focusing on timely records, examine the following entries as you conduct a tracer review:

-H&Ps
-Nursing assessments
-Response to referrals
-Informed consents
-Operative reports

3. To make sure all records are legible:

-ask yourself whether all entries are legible and free from abbreviations not approved for use

-start with entries related to patient safety, such as orders, especially for medications

When performing your own tracer reviews, the oversight group, or a specially assigned team, selects records at random, one for each team member. It is preferable to use open records, but closed records can be used as well. Each team member should review the medical record and visit each unit or department encountered by the patient during the hospitalization. Findings from the reviews can be incorporated into the ongoing records review reports and will help to identify areas of focused reviews or opportunities for improvement.

This week's excerpt is from the book, "Ongoing Records Review: A guide to JCAHO compliance and best practice," by Jean S. Clark, RHIA. See Editor's Choice below for more information or click here to order.

Check out the Editor's Choice section below for solutions to your records completion problems.

Kate Alvarez
Editorial Assistant kalvarez@hcpro.com

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