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Know the JCAHO's ongoing records review requirements

HIM-HIPAA Insider, December 6, 2005

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The requirement to conduct ongoing records review (ORR) is still part of the Management of Information (IM) standards, but the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) expectations are not as prescriptive as they were in the past. In fact, they are very flexible, which may cause some concern to hospitals that are accustomed to conducting reviews in a directed way. The new requirement for ORR will provide much more opportunity to resolve problem areas and to focus on topics with real relevance.

The requirement for ORR is listed as element of performance (EP) 12 and EP 13 under standard IM.6.10.

Consider these requirements for ORR:

• Records must be reviewed on an ongoing basis at the point of care
• Hospital indicators must address the following:
  • Presence: Is the required data available? For example, is the history and physical (H&P) on the paper record or available electronically?
  • Timeliness: Are documents available according to standards, organization policy, and state/federal laws? Is care provided to the patient in the most beneficial and necessary time? For example, is the H&P report on the chart or available electronically within 24 hours of a patient's admission to the hospital?
  • Readability: (whether handwritten or printed) Are the entries legible and easy to read? For example, is the handwritten H&P legible and understandable? Are copies of reports legible and free of obstructive marks?
  • Quality: Does the documentation reflect an accurate picture of the care and treatment provided? Is it meaningful and appropriate to the encounter? For example, does the H&P contain all the items required by hospital policy and additional information relevant to the condition for which the patient is being treated?
  • Consistency: Does the medical record consistently reflect good standards of documentation practices and principles? Are the forms or computer screens standardized? For example, all paper forms are required to have the patient label in the top, right-hand corner and the name of the organization in the top left. All forms must be identified as to purpose. The menus for charting are consistent for all types of data entry.
  • Clarity: Are all entries clear as to their meaning? For example, do all orders for medications contain information about who gave the order, who received and recorded the order, the type of medication, the dosage, and the time period to administer it?
  • Accuracy: Are entries free from error and according to documentation guidelines? For example, are all the transcribed reports free of blanks?
  • Completeness: Does the medical record contain all the reports and documentation to support the treatment provided? For example, is the medical record complete according to policy and the care that was given?
  • Authentication of data and information that is located in the record: Has the medical record been validated for correctness for both the information itself and the person who is the author of the information? For example, at the time of discharge, the record is analyzed for appropriate reports and signatures.

The open record
The focus of ORR is to be at the point of care. There is no mention of reviews after discharge, but the HIM department can still conduct reviews for items, such as the following:

• Discharge summaries-Timeliness, content, authentication
• Autopsy reports-Timeliness, content, authentication
• Other reports such as H&Ps, operative reports, consults, signatures, etc., can be aggregated from the incomplete analysis system and reported regularly to the medical staff

The JCAHO's focus for reviews at the point of care makes sense: Caregivers who make entries in the record can make timely corrections while the patient is being treated, which ensures better communication among caregivers, which ultimately results in quality care and safety for the patient.

Editor's note: This article was adapted from HCPro's book, Information Management: The Compliance Guide to the JCAHO's Standards, Fifth Edition.

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