THE MEDICAL RECORD REVIEW PROCESS - A BENEFITS ANALYSIS

 

Assumptions:

The facility has an interdisciplinary team review the charts.

The data from the reviews is manually entered into the tracking system.

The facility is conducting both open and closed reviews, as per JCAHO requirements.

 

JCAHO REVISIONS: (as per Medical Record Review, published by JCAHO)

 

The revisions:

  • Now require ongoing monitoring of medical record content, rather than quarterly reviews;
  • Focus the reviews on the information available at the point of care (Open Reviews);
  • Delete the requirement for annual review of medical records from each physician on the medical staff; and
  • Provide latitude to organizations in determining their own priorities for improving information management processes related to the medical record.

 

According to JCAHO, how can your hospital demonstrate compliance?

ü       By developing and implementing a medical record review program for the ongoing review of the completeness and timeliness of information; and

 

ü       By taking action to improve the quality and timeliness of documentation that impacts patient care.

 

Your hospital must show that

·         Medical records are reviewed on an ongoing basis;

·         Findings are available at least quarterly;

·         Performance improvement activities address findings, as appropriate; and

·         Appropriate individuals are involved in the review.

 

Who should be involved in the medical record review process?

 

The review process should include medical staff, nursing staff, and other relevant professionals who are intimately familiar with the documentation required by the patient-focused standards and selected information management standards.

 

All such staff members are not required to be involved with the review process at all stages of the review. For example, typically in hospitals, medical records or information management specialists will complete the initial records screening. When they encounter issues of a clinical nature, they involve nurses and physicians, as appropriate.

 

The Role of CCMS in the Review Process

 

Data Collection                                    Data Presentation                    Consultation Services

 

We will collect your data on all open and closed medical records, collate the data, and present the final tabulations to the Chief of the Medical Records Review Committee. The Committee will then evaluate and interpret the data and take corrective action to implement quality improvements.

                                                                                                                        

                                                                                                                        

ü All the Open and Closed reviews your facility requires to be in compliance with JCAHO

ü Data presented in table and graph format for easy interpretation;

ü Data collection by unbiased professionals; and

ü Data collection supervised and coordinated by Healthcare professionals;

ü Data will be RELIABLE, TIMELY and COST EFFECTIVE