Health Information Management

Medical record committee protocol: What will be reviewed, who will conduct the reviews, and how often?

HIM-HIPAA Insider, July 13, 2004

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Because your healthcare facility activities might require an interdisciplinary review team, your organization may find that an existing group, team, or committee is well suited to oversee ORR. The medical records committee, if it exists in your organization, is already familiar with medical records and performs activities similar to ORR, such as analyzing medical records for completeness and timeliness. The example below illustrates a protocol for a medical record committee with ongoing records review oversight. However, the example could be modified for any group charged with this responsibility.

If your organization is smaller, the performance improvement (PI) committee or the medical executive committee can serve as the oversight group. Generally, the oversight group does not review records, but coordinates the process by establishing indicators, deciding how often reviews will occur, receiving and analyzing reports, and deciding what focused reviews should be implemented.

Protocol for a medical records committee with ongoing records review oversight
Purpose
The medical records committee will have oversight for the organization's ongoing records review program, the review and approval of forms and format for the medical record, including electronic applications.

Scope
All types of medical records and related functions, including paper based and electronic.

Responsibilities
Coordination and oversight of the organization's ongoing records review program includes:

  • Establishing the calendar for reviews
  • Assisting with topic and indicator selection
  • Establishing focused reviews
  • Analyzing data from reviews, and taking action as soon as appropriate
  • Conducting point of care reviews using the tracer methodology
  • Reporting to appropriate organization and medical staff committees
  • Review and approval of forms and format for the medical record, including electronic applications
  • Review of the monthly delinquent record statistics and taking action as needed
  • Other duties as relate to the documentation, use, and storage of medical records

Membership
Membership will include physicians, nurses, other clinical care providers, HIM managers and others identified by the committee. A physician in good standing on the medical staff will chair the committee.

Meetings
Meetings will occur monthly on the first Tuesday of each month at 7:00 am.

Reporting
Departments and nursing units will report bi-monthly (based on a schedule published in January of each year). The committee will report quarterly to the PI council and the medical executive committee.

Statement of confidentiality
Members of the committee will honor patients' rights to privacy with respect to information in the medical records. All reports will be free of patient identifiers.

The leadership of your organization will have to decide whether the oversight group or the departments select the topics and indicators for review, who will collect the information, and how often departments report to the oversight group. The most successful approach would be to have the oversight group and the departments agree on review topics and indicators or focused reviews based on previous data related to ongoing records review.

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. Check out our Editor's Choice below for excellent solutions to your documentation problems.



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