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Report initial findings and identify problem records

HIM Connection, April 26, 2005

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If you are responsible for reviewing records and gathering data, you should submit reports that include, at a minimum, the following information:

• The types of records reviewed
• The time period during which the information was gathered
• The total number of records reviewed
• The number of records found in compliance with the criteria
• Descriptions of problems uncovered, if applicable

If a computer application is used, review of the records and data entry becomes the task of the reviewers. The facilitator then collects the data and prepares the reports that include the above information. That staff that collect the data and prepare the reports should also consider noting the percentages of records reviewed and found in compliance with criteria, to make the data more meaningful. For example, learning that 85% of records were in compliance with an indicator may be more insightful than seeing that 121 of 142 records were in compliance.

Prepare reports in simple, easy-to-read formats. Graphs or control charts are much more meaningful than a written report. However, reports may simply document the results in checklists similar to those that were used to review records. Include brief notes describing identified problems. If the reports will be presented to an oversight committee, include actions already implemented by the department.

However the reporting structure is set up for ongoing reviews, follow-up reports should be forthcoming to ensure resolution to all identified noncompliance issues. This information will be helpful at the time of the periodic performance review.

This excerpt is adapted from Automating Ongoing Record Review, 2nd Edition, Enhanced Strategies for JCAHO Success.

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