Health Information Management

Improve documentation with 15 tips for timely record completion

HIM-HIPAA Insider, January 11, 2005

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The JCAHO is serious about record timeliness and completion. Surveyors frequently cite hospitals failing to meet basic records completion requirements related to delinquent records. Surveyors look to medical records documentation in open records more and more frequently as evidence that the hospital carries out its policies and procedures in many clinical and administrative areas, including patient rights, patient education, leadership, and the medical staff. Not withstanding the fact the JCAHO takes timely documentation seriously, it is critically important to patient care, both during and after treatment. Read on for 15 tips to improve documentation at your facility.

15 tips for improving the timeliness of record completion

  1. As part of the medical records tracking system, produce regular reports showing the number of days after discharge records are completed.

  2. Keep basic records completion data on a database. Present that information to the committee/team in charge of medical records timeliness so it has an ongoing look at completion cycles. Implement a computerized tracking system.

  3. Present such information geographically; it's generally more meaningful to the committee.

  4. Compare delinquency percentages to patient volume so offenders stand out.

  5. Provide areas for physicians to complete records that are pleasant, clean, and neat. Paint the room. Try not to have stacks of records lying around.

  6. Send records needing to be signed to physicians via courier service, or fax reports. If physicians don't sign the reports in two days, discontinue the service.

  7. Use physician extenders to dictate histories and physicals, with the attending physician countersigning them within 24 hours.

  8. If physicians don't complete their discharge summaries on time, have a resident complete the documentation and send the physician a bill for the time.

  9. Find out what physicians prefer-the specific days and times most convenient to them for record completion. Then tell each physician the department can have the incomplete records ready at his or her time. All physicians are not equal. Determine what method works for each one and use it.

  10. Ask physicians to call the HIM department a few minutes or hours before they plan to complete records. That way, staff can have the records ready for the physician.

  11. Establish a rule that all incomplete records must remain in the department (exception: patient care). If incomplete records are needed for other reasons, such as quality review, staff must come to the department to view them.

  12. During concurrent review, before flagging a record for a missing report, check the dictation system to find out whether it's been dictated.

  13. Assign different colored stickers to each physician. Then, as staff review records for completion, they signal missing items by the color unique to the physician responsible.

  14. Use color-coding-red is especially noticeable-to indicate documents that need immediate signing, such as operative reports.

  15. On admission, put a records completion checklist on the front of the chart and have everyone who puts any documentation in the record indicate when that's accomplished. That eliminates work for the HIM department after the patient is discharged as well as makes missing elements obvious to the attending physician.

This excerpt is adapted from the book Ongoing Records Review, 3rd Edition: A Guide to JCAHO Compliance and Best Practices.

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