Health Information Management

Clarification after an RC survey

HIM-HIPAA Insider, July 28, 2014

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Have you considered seeking clarifications after a Joint Commission survey for the Record of Care (RC) Requirements for Improvement (RFI)?
A healthcare organization almost always receives an RFI after a survey by The Joint Commission (TJC). For the past few years, the most frequent RFI has been RC.01.01.01, signing, dating, and timing entries in the medical record. Of course, others pop up from time to time, including timely history and physical examinations (H&P), the update to the H&P, timely operative reports, lack of elements in the postoperative note (most often specimen and estimated blood loss), and the pre- and post-anesthesia evaluations.
The RC Elements of Performance (EP) are easy targets at the time of survey, because medical records usually yield two or three deficiencies resulting in RFIs. As a reminder, EPs are categorized as A or C. Scoring category A is assigned to EPs that may present immediate harm to patient care, quality, and safety. If scoring category A is assigned, the deficiency must be corrected within 45 days of a survey with 100% resolution. EPs scored as category C are unlikely to cause immediate harm to patient care, quality, and safety. Therefore, corrective action is required within 60 days of a survey with a 90% compliance rate.
The good news is that most EPs fall within scoring category C, thereby requiring 90% compliance and 60 days to provide Evidence of Standards.
Of course, the EPs scored as category A are more difficult to clarify, but not impossible. Organizations have 10 days after a survey to submit a clarification, so don't delay.
Jean S. Clark, RHIA, CSHA, interim HIM director at Cadence Health in Chicago, wrote this article. Continue reading "Clarification after an RC survey" on the HCPro website. Subscribers to Medical Records Briefing have free access to this article in the July issue.


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