Health Information Management

Topic: Monitor timeliness of records completion

HIM-HIPAA Insider, April 10, 2007

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Medical record completion was a problem well before The Joint Commission existed. In 1919, when the American College of Surgeons first set minimum standards for hospitals, the standards included a mandate for accurate and complete records for all patients--and defined "complete" much as The Joint Commission does today. By 1929, however, records completion was a known problem: Indeed, the Association of Record Librarians of North America, the precursor to the American Health Information Management Association (AHIMA), devoted part of its first annual meeting to the issue.

Today, hospitals continue to receive low scores related to timely documentation of operative reports, documentation of postoperative progress notes, and delinquent medical records after discharge. Numerous other requirements for timely documentation are also problematic. For example, The Joint Commission frequently cites documentation of time-limited orders for restraints in its hospital surveys.

Why is timely record completion so important?

The Joint Commission is serious about records timeliness and completion. Surveyors frequently cite hospitals for failing to meet basic records completion requirements related to delinquent records.

Surveyors look to medical records documentation in open records more and more frequently as evidence that the hospital carries out its policies and procedures in many clinical and administrative areas, including patient rights, patient education, leadership, and the medical staff. In addition to the fact that The Joint Commission takes timely documentation seriously, it is critically important to patient care, both during and after treatment.

What's changed?

Nothing much has changed in The Joint Commission standards related to delinquent records.

Even though the delinquent rates continue to be calculated based upon "overall" delinquent rates, it is a good idea to keep track of the types of delinquencies. For example, are most of your records delinquent because reports are not dictated or because documents are unsigned? Because timeliness and completeness are parts of ongoing records review requirements, your organization can use this data to good advantage in helping to identify both targeted document types and departments or individuals for focused reviews.

If you wish to do so, your organization still can include in its records review calculations any outpatient record that is analyzed in the delinquent records calculations. Some organizations may continue to include other caregivers besides physicians in their incomplete record analysis, although doing so can be very time-consuming and is usually a manual process, as most computer systems do not accommodate other caregivers. Therefore, focus on physician record completion for the incomplete record analysis and delinquent process after discharge. Leave identification of timely completion problems for other disciplines to address as part of their records review process. If you have problems with incomplete or late entries, a good open records review process will identify such issues quickly.

Editor's note: The above article was adapted from the book Ongoing Records Review: A Guide to The Joint Commission Compliance and Best Practice, Fifth Edition, written by Jean S. Clark, RHIA. For more information or to order, call 877/727-1728 or click here.

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