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Work tracer methodology into ORR

HIM Connection, January 31, 2006

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Last week's edition of HIM Connection reviewed how the Joint Commission on Accreditation of Healthcare Organization's (JCAHO's) tracer methodology works and how documentation fits into the ongoing records review (ORR) process. Click here to read the first article.

Using the tracer methodology as part of your regular ORR will alert reviewers to the importance of timely and accurate documentation in the medical record and gelp your staff know what to expect during the actual survey. More importantly, it will help to identify inconsistencies in care and documentation, as well as demonstrate the importance of communication and teamwork among caregivers.

Identify PFAs and CSGs
To get started in using tracers as part of your ORR, first put yourself in the place of the surveyors. What will they do? They will know the standards and elements of performance (EP), the National Patient Safety Goals (NPSG), the organization's priority focus areas (PFA) and clinical service groups (CSG). (Note: You should be able to access your own PFA and CSG on your organization's secured JAYCO site.)

Examples of PFAs are assessment and care, communication, information management, and infection control. CSGs include cardiac surgery, oncology, orthopedics, and psychiatry, to name a few. Both are based upon the organization's specific data and services that it provides, and this information helps surveyors determine which patients they should trace. Therefore, your first steps toward incorporating tracers into ORR will be to

• identify the organization's CSG
• identify the organization's PFA
• select the CSGs and PFAs that will be the focus of the reviews
• identify the patients

Your organization can determine who will participate in ORR. However, when you use the tracer methodology for reviews, it is even more important to use currently active patients in the hospital for your reviews and caregivers as your reviewers. The HIM staff, as usual, can help facilitate the process.

Decide how to conduct the review
Try conducting the reviews either at the department level, which helps get the appropriate staff involved, or through a team approach of reviewing recently discharged records. One hospital started its tracer approach to ORR by introducing the concept at the monthly nursing team leader meeting. The HIM director brought recently discharged records to the monthly meetings and asked teams of two nurses to review one record. After the reviews were completed, the teams presented their findings. It was an eye-opener for the reviewers, who have replicated the process on their units.

Getting started requires the following steps:

• identify the reviewers
• identify the process (at the units or after discharge)
• select the records
• review the records and chart the path of the patient
• review the records and record issues related to documentation

There are numerous benefits to using this methodology for chart reviews, but the primary one is that the process immediately identifies issues and validates the importance of accurate and timely medical records.

This article was adapted from the book Ongoing Records Review: A Guide to JCAHO Compliance and Best Practice, Fourth Edition.

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