D.48- HIMS MEDICAL RECORD REVIEWS.pdf

DEPARTMENT OF VETERANS AFFAIRS

VA HEALTHCARE NETWORK

UPSTATE NEW YORK AT SYRACUSE

Medical Center Memorandum October 2017 Health Information Management HIMS-06

MEDICAL RECORD REVIEWS

I. PURPOSE :

The purpose of this policy to outline the process by which medical records are assessed, corrected and monitored to ensure medical record documentation is accurate, complete and timely. This will outline the process of ongoing record reviews as required by Joint Commission (JC) (IM 6.10).

II. RESPONSIBILITIES :

A. The Health Information Committee is responsible for establishing review criteria, analyzing review findings, ensuring appropriate actions are taken and reporting monthly to the Medical Staff Executive Council (MSEC).

B. Specialty Leads or Points of Contact (i.e. clinical staff) from the various specialty areas of the organization are responsible for reviewing medical record documentation for their area. The leads are staff from various disciplines of the medical center to include physicians, nurses, social workers, nutritionists, psychologists, rehab specialists, and administrative staff.

C. The Chief of HIMS or designee is responsible for coordinating the overall ongoing records review program. Responsibility shall include assignment of specialty leads, record review tool revisions, orientation and training of the review tool and ensuring data is compiled and aggregated so in a reportable format to the Health Information Committee (HIC).

III. SCOPE :

The scope of the ongoing record review program includes inpatient and outpatient reviews in the areas of Neurology, Surgery, Medicine, Geriatrics, Behavioral Health, Primary Care, Emergency Department, Rehab Medicine, Nutrition, Social Work, and Nursing.

Attachment D.48 RFP 36C24224R0049

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IV. CRITERIA :

Appropriate criteria may be selected accordingly by the Medical Records Committee or by the interdisciplinary team conducting the reviews. The JC Medical Record review form will be used as the selected criteria. Additional criteria such as known problematic areas or specific documentation elements common to a specialty area may be selected accordingly by that specialty lead with Health Information Committee approval.

V. ACTION AND REPORTING :

Data from record reviews through all review processes shall be compiled, aggregated, and reported to the Health Information Committee at its regular meeting. Minutes of the Health Information Committee that include results of the open record reviews shall be reported to the Medical Staff Executive Council.

Findings and recommendations resulting from reviews shall be shared with appropriate units, committees and departments as indicated.

VI. ONGOING MEDICAL RECORDS REVIEW PROCESS :

A. Treating specialties (e.g. Neurology, Surgery, Medicine, Geriatrics, Behavioral Health, Primary Care, Emergency Department) will use a specified version of the 86-item JC Medical Record Review Tool including core elements that are multi-disciplinary for open and closed records. A specific review tool will be used for inpatient and outpatient records (See Attachments A and B). Other specialty areas such as Nutrition, Social Work, Rehab Medicine and Nursing will use a review tool that is a combination of JC elements and documentation requirements outlined in the local policy for that specialty (i.e. peer reviews). Changes to the review tool will be made on an as needed basis to assess documentation issues in each of the areas. The most recent version of the inpatient and outpatient review tools will be made available to all reviewers on a shared drive.

B. Specialty leads will complete a review of 10 records per month. For inpatient record reviews, eight (8) will be open records and two (2) will be closed records. For outpatient reviews, all 10 records reviewed will be closed records. Selection will be current and random, however each provider in that specialty area should be reviewed annually.

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1. Primary Care will select records at random from the clinic visits.

This process will include the CBOC's.

2. Inpatient services will select open records from the inpatient roster.

or other report used internally to identify active inpatients.

C. Specialty leads will report the findings of their monthly reviews on a quarterly basis to the Health Information Committee. A medical record review reporting schedule will be established by the Health Information Committee at the beginning of each fiscal year and distributed to the specialty leads.

D. Results will be tabulated and the summary sheet reviewed at the Health Information Committee meetings. Performance Improvement initiatives will be developed and implemented for areas outside of the target goal of 85%.

E. The record review tool will consist of JC core elements from the Care, Treatment, and Services (CTS), Information Management (IM), Medication Management (MM) and Patient Rights (RI) standards and will be incorporated into all specialty reviews involving inpatients. For any of the elements that may not apply to a particular record reviewed, the reviewer should indicate as “NA” or Not Applicable when completing the review and therefore not include in the denominator when calculating the results for that element.

1. Advance Directives:

a. Definition: Written instructions which outline an individual's health care wishes; to be utilized when the individual can no longer make their wishes known.

b. Types of Advance Directives:

1. Health Care Proxy

2. DNR (Do Not Resuscitate Order)

3. Living Wills

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4. Power of Attorney

c. Physicians are ultimately responsible for seeing that the Advance Directives are addressed in the patient's chart.

2. Assessment of Patients

a. This section must be completed for all Inpatients and Ambulatory Surgery Patients.

3. Care Plans

a. This section must be completed for all Inpatients and Ambulatory Surgery Patients. Should be completed for clinic patients as appropriate to the patient’s condition.

4. Orders

a. This section must be completed for all Inpatients and Ambulatory Surgery Patients.

5. Informed Consents

a. This section must be completed for all Inpatients and Ambulatory Surgery Patients.

6. High Risk Procedures And/or Sedation and Anesthesia

a. This section must be completed for all Inpatients having a high risk surgical procedure, Ambulatory Surgery Patients, Emergency Room Patients or any clinic patients in which the patient went to the Operating Room for a high risk procedure.

7. Restraint for Acute and Surgical Care

a. This section must be completed for any patients that are restrained

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8. Medication Reconciliation

a. This section must be completed for all Inpatients, Outpatients, and Ambulatory Surgery Patients.

9. Patient Education

a. This section must be completed for all Inpatients and Ambulatory Surgery Patients.

10. Discharge Information

a. This section must be completed for all Inpatients and Ambulatory Surgery Patients.

b. Please note: Some of these questions may be NA for Ambulatory Surgery Patients.

F. The record review tool for outpatient clinic patients will consist of JC core elements from the Information Management (IM) and Point of Care (PC) standards.

1. Significant diagnosis, procedures, drug allergies, and medications.

2. General Items

3. Documentation of Care of Patients

4. Education

IX. REFERENCES :

JCAHO Accreditation Manual, 2014 and the JCAHO Website.

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VIII. RESCISSION:

Medical Center Memorandum HIMS-06 Medical Record Reviews dated July 2014.

IX. REVIEW DATE:

October 2019

X. RESPONSIBLE REVEIWER :

HIMS Manager

JUDY HAYMAN, Ph.D.

Acting Medical Center Director

Attachments: Attachment A – Medical Record Review Process

Attachment A: Medical Record Review Process

Screening of Open/Closed Records Using JCAHO 88-item Tool

Review Criteria Reviewed for Deficiencies

Deficiencies sorted into Physician & Nursing

Lead Physician* to Complete Clinical Pertinence Review and Review of Deficiencies

Deficiencies FoundYes No No Further Action Needed

Lead Physician* Finds Areas of Deficiency for

JCAHO JC 88-

Item Review

Lead Physician * Finds Areas of Deficiency for Clinical Pertinence Review

No

Yes

No

Yes

Case Referred to Departmental Meetings for Discussion

No Further Action Required

No Further Action Required

Case referred to Medical Records Committee & Medical Staff Committees for Discussion

Physician of Record Notified of Quality of Care Issue

Case Possibly Referred to Peer Review Committee for Discussion

Physician

Nursing Nurse Executive to Review Deficiencies

Finds Areas of Deficiency for JCAHO JC 88-item Review

No

Yes

No Further Action Needed