HITT 1401- Lab part 2

Assuring that the record meets all documentation requirements

Checking for errors and inconsistencies in documentation

Verifying that the record meets all legal requirements

Abstracting / compiling statistical data for tracking and trending purposes

• Reviews of charts performed in addition to quantitative analysis to determine whether specific required or forbidden elements are present
• – These reviews are not performed for completion purposes, but rather to determine whether standards/policies are being followed
• – CP items are selected by the facility

Any review performed while the patient remains hospitalized

Any review performed after the patient was discharged from the facility

Joint Commission requirement: In order to meet the 30-day completion requirement, the facility should provide equal access to incomplete records.

A medical record with specific deficiencies that can be completed by a health care provider

• An incomplete medical record that has not
• been completed within the time specified in the medical staff bylaws

• Steps:
• 1– Assembly (paper records)
• 2– Analysis for completeness
• 3• AKA Deficiency Review
• 4• AKA Incomplete chart review
• 5– Re-analysis

• Explained:
• Assemble record in order (paper records) – Order is established by the Med Rec Cmtee – This process can be started at the nursing unit
• • Analyze for deficiencies – Identify missing forms, reports – Identify missing signatures
• • Indicate deficiencies for each doctor on a deficiency report; notify physicians
• • File the record in the incomplete file (paper) so that it is available for doctors to complete, on request
• • Re-analyze until all deficiencies are corrected
• • Perform a final recheck
• • File in permanent file (paper) or

• Manual (Paper)
• – Mark deficiencies with a colored tab
• – Send list of incomplete records to the physician
• – Pull the charts for the physician to complete
• – Transcribe
• – Repeat process for signatures
• – Do recheck, final analysis

• Electronic
• – Send email notice to physician regarding items to be completed
• – Physician accesses charts electronically from the hospital, office or home
• – Physician dictates reports, signs entries electronically
• – Do recheck, final analysis

• HIM Department – perform incomplete and delinquent chart counts weekly
• • Physicians should receive a warning if they have charts reaching “delinquent status”
• • All physicians with delinquent charts should be placed on the hospital’s “Delinquent List” (usually referred to as “Suspension list”)
• • Admissions Department should be required to check the physician’s status on the Suspension List prior to admitting patients
• • Requires absolute administrative support

Other concrete steps that health information management (HIM) staffs can take include:

• -Producing regular reports that show the number of days after discharge records are completed
• -Sharing a basic records completion database with the medical records committee
• -Implementing a computerized tracking system
• -Comparing delinquency percentages to patient volume to highlight offenders
• -Providing a pleasant, clean area for physicians to complete records
• -Using physician extenders to dictate histories and physicals, with the attending physician countersigning them within 24 hours
• -Having a resident complete the documentation and billing the physician for the time if physicians don't complete discharge summaries on time
• -Finding out specific days and times physicians prefer for records completion and having incomplete records ready then
• -Asking physicians to call the HIM department before they plan to complete records so the staff can have records ready

• All necessary forms and reports
• • Must be signed (and dated) as required by
• accreditation standards
• – H&P
• – Discharge Summary (physician)
• – Orders
• – Progress notes (physician, nursing, allied health)
• – Operative Set
• – Nursing Forms
• • TPR, Graphic, notes, Discharge Note/Pt
• Instructions
• – Diagnostic (Radiology, Lab, etc)

# of incomplete charts x100/ # of discharges [or other patient care episodes] during the required completion period

25 incomplete records x100 / 75 discharges =.3333= 33%

# of delinquent records / average # of discharges during the stated time period

• • 50% of average discharges = 75/2 = 37.5
• 50 delinquent records > 37.5 (must address reasons for excessive number)
• • 2x avg discharge rate = 75x2 = 150.
• Currently not subject to conditional accreditation

The number of delinquent records should not exceed 50% of the average number of discharged patients per quarter over the previous 12 months

• • If the average of the total number of delinquent records averaged over the 12 months before the survey is equal to or exceeds twice the average monthly discharges, the hospital will be cited for
• conditional accreditation

• • The hospital must measure medical record delinquency at regular intervals, no less
• frequently than every three months, and must report the data as part of the medical
• record review function

• JC requirements:
• A medical record is considered delinquent
• when it has not been completed within a
• specified time following the patient’s
• discharge
• • This time period must be stated in the
• medical staff bylaws and cannot exceed 30
• days