Health Information Management

Establish an ongoing records review process with five easy steps

HIM-HIPAA Insider, April 4, 2006

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Just because the requirements for ongoing record reviews have been changed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), does not mean you have to totally redo your process. Conducting a simple assessment will help your organization identify ways to improve and simplify its process in view of the flexibility now afforded by the standard and elements of performance.

To make your ongoing records review a success:

1. Decide what to review, who will conduct the reviews, and how often to conduct reviews
Because many healthcare facility activities require interdisciplinary review teams, an organization may find that an existing group, team, or committee is well-suited to oversee ongoing records review. The medical records committee, if one exists in the organization, is already familiar with the medical records and performs activities similar to ongoing records review, such as analyzing medical records for completeness and timeliness.

In smaller organizations, the performance improvement (PI) committee or the medical executive committee can serve as the oversight group. Such a group generally does not review records but rather coordinates the process by helping to establish indicators, deciding how often reviews will occur, receiving and analyzing reports, and deciding what focused reviews the organization should carry out.

The organization's leadership must decide who selects the topics and indicators for review (i.e., the oversight group or departments), who will collect the information, and how often departments will 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.

2. Review the records
Actual reviews of the medical records should occur at the point of care by the individuals who either document in the records or enter data into the electronic record. Note that HIM department staff (i.e., coders, record analysts, and managers) can assist with any retrospective reviews that may be necessary and, ideally, will review records for completeness, authentication, and quality of discharge summaries. They also can serve as backup reviewers for unapproved abbreviations and legibility.

3. Collect and organize data
This function is ideally suited to the HIM director or the PI director, both of whom are skilled at aggregating, displaying, and analyzing data and information. Ideally the record reviewers enter their findings into a computer software program that is networked throughout the organization. Then collecting and organizing data become a simple matter of running reports for the oversight group and for the departments conducting the reviews. There are software applications on the market, as well as "home grown" systems, that can make data collection and report generation much easier.

4. Analyze the data and take action
The oversight group generally analyzes data and takes appropriate action, but because each department that conducts reviews can receive task assignments, be sure to establish and adhere to a schedule for reporting the oversight group. Such a well-structured process will help emphasize the importance of ongoing records review and tress to all involved that they should not take this process lightly.

5. Assemble and oversight team specifically for ongoing records review
Although some organizations use established committees or combine the ongoing records review oversight function with other reviews, other organizations choose to create an interdisciplinary team dedicated to ongoing records review. The latter approach may help draw attention to the importance of ongoing records review and may help a facility assemble a group of professionals who are interested in and committed to the process.

Editor's Note: This article was excerpted from HCPro, Inc.'s book Ongoing Records Review, Fourth Edition: A Guide to JCAHO Compliance and Best Practices, written by Jean S. Clark, RHIA. For more information or to order go to or call 877/727-1728.

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