Health Information Management

Master ongoing record review for survey success

HIM-HIPAA Insider, May 11, 2010

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Although The Joint Commission has not focused on the ongoing record review (ORR) process during surveys and hospitals have not received recommendations for improvement in this area, ORR is still vital to the success of any survey, says Jean S. Clark, RHIA, CSHA. The relevant standard and EP is as follows:

RC.01.04.01. Medical records must be audited.
 
1. Medical records must be audited/reviewed on a regular basis and at the point of care. Indicators should consider the following about the information and data found in the medical record: presence, timeliness, legibility (handwritten or printed), accuracy, authentication, and completeness.
 
Clark provides the following tips for ORR:
  • Don’t waste time reviewing records after discharge. The standard does not require it, and the surveyors will only be looking at your records on the units and in the outpatient areas. The only time they may ask for closed records would be when insufficient records for a particular tracer situation are available (e.g., for patients in restraints).
  • Use the chapter on Record Care as the foundation for your indicators. It’s all there, so why reinvent the wheel? This is what the surveyors will look for in the medical records, so it is critical to ensure that it is available at the time of the survey. The medical record still serves as the road map for patient and system tracers.
  • Don’t forget to use your findings. Often, we audit ourselves to death but never actually correct anything. Take the findings to the people who can fix them. This is often the medical executive, nursing leadership, or quality committees.
Editor’s note: For additional tips, see the May issue of Medical Records Briefing.



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