Establishing or updating your ongoing records review process
HIM Connection, July 7, 2004
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The Joint Commission on Accreditation of Healthcare organization's (JCAHO) ongoing records review standard and element of performance outline some specific requirements for records review, but they are far less detailed than the JCAHO's previous records review standards. The intent is to provide organizations with flexibility in developing a process that best suits it needs. Each organization will have broad discretion in deciding the who, what, where, when and how of ongoing records review. However, the danger posed by this flexibility is that it could result in a less effective process.
To change or not to change
Just because the requirements have changed does not mean that you have to totally redo your process. In fact, here are a few questions your organization should ask:
Conducting this simple assessment will help your organization identify ways to improve and simplify their process in view of the flexibility now afforded by the standard and EP.
Components of a records review process
A good records review process still consists of the following five major components:
- Identifying what will be reviewed, who will conduct the reviews, and how often
- Reviewing the records
- Collecting and organizing the data
- Analyzing the data
- Taking action to resolve variations
This review process usually involves the following three groups of professionals:
- Individuals actually reviewing the records
- Support staff who organize the data
- Group (or individual) that oversees the overall ongoing records review program
An existing team or committee provides all or a portion of the five major components of the process. Whatever the structure is, someone needs to take the lead and become the expert in the requirements and begin the process of revitalizing the organization's ongoing records and review program.
Next week: What will be reviewed, who will conduct the reviews, and how often?
This excerpt is adapted from the book Ongoing Records Review: A guide to JCAHO compliance and best practice. Click here to order or learn more.
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