Important decisions and activities for ORR
HIM Connection, April 6, 2004
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You need more than just an understanding of the JCAHO standards to establish an effective ongoing records review (ORR) program and comply with the Joint Commission. ORR success hinges on your ability to make informed decisions and design well-planned, well-executed activities related to records review.
To plan your ORR program, you must
* pick indicators to measure compliance with IM.6.10, EP 11
* decide how often you will carry out ORR (weekly, monthly, as issues arise, etc.)
* assign an individual to review the records
* select a method for identification of performance-improvement
opportunities
* outline how and by whom ORR will be aggregated and summarized into
meaningful information
* settle how you will gather representative samples
* choose how, how often, and to whom ORR findings will be presented
* determine how the facility will document its ORR activities, actions, and
improvements for JCAHO periodic performance review and on-site survey
In coordination with making the above decisions, plan and execute the following activities:
* Train individuals responsible for records review
* Gather representative samples (if appropriate) of medical records for reviews
* Analyze items in medical records against established records-review
indicators
* Present data to the group overseeing ORR
* Report ORR-related findings to appropriate individuals, committees,
departments, and other groups
* Plan and implement performance-improvement activities to enhance
medical-records documentation based upon ORR findings
* Document actions and improvements related to ORR
Because the element of performance regarding ORR provides minimal guidance for planning and executing your program, you must develop an ORR program to meet the needs of your particular organization. For this reason, make the above decisions and plan the above activities yourself.
This week's excerpt is adapted from the book, "Ongoing Records Review: A guide to JCAHO compliance and best practices, third edition," written by Jean S. Clark, RHIA. Visit http://www.hcmarketplace.com/Prod.cfm?id=1923&s=EHIMC to order or learn more.
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