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Knowledge Point Articles   

February 2007

Does Your Medical Record Measure Up?

How does your medical record measure up to today’s standards? With consumers of health care becoming more aware of their rights to access records and health care standards, does your record measure up to expectations? This is a question we must all ask ourselves. The medical record is the key to accurate reimbursement, successful surveys and will support the facility during litigation. The record must accurately document the treatment provided, the resident’s response to treatment and the services billed.

The most successful way to ensure adequate documentation is through a stringent auditing schedule, which requires frequent review of the entire record. The facility should utilize the results of the audits to determine further educational needs for staff. This is where most facilities fall short. The audits are completed, but most facilities don’t aggregate the data to view trends and further educate staff. The medical record should be reviewed with State/Federal regulations, reimbursement and a jury in mind. Look at your current auditing functions and tools utilized. Ask yourself these questions:

• Are the audits completed routinely?
• What is done with the audits after they are completed?
• How many educational in-services were conducted as a result of auditing functions?

If the answers to the above questions are not positive, you may need to revise your processes. In spite of what some may think (auditing is a waste of time, no one looks at audits, I am too busy to audit etc.), auditing can be your best defense against poor care practices. In short, the care can be excellent, but if the documentation is poor the excellent care will not be reflected. Remember, if it is not documented, it was not done.  

The Medical record should at a minimum be reviewed on admission, within 21 days of admission, quarterly and at the time of discharge. Audit results should be reported to administration, analyzed and acted upon. Use tools that show trends/patterns in documentation and improvements. I also recommend that you utilize a tool that starts at the time of admission and continues for a year on the same chart.

Briggs Medical Record Audit Form 1136P is one audit tool that is available. For example, utilize one medical record audit tool for each resident concurrently in the facility. Place the audits in a binder separated alphabetically by last name and use file guides to insure easy access. Complete the quarterly section of the audit one-week after the resident is care conferenced. Upon the admission of a new resident, pull a new audit sheet and complete the admission portion of the audit. When a resident is readmitted, utilize the readmission section of this audit form to complete the audit. Upon discharge of a resident pull the audit form from the book and complete the Briggs discharge audit. Review the audit results monthly through the facility risk or Quality Assurance committee. Also review the results with the facility staff in-service coordinator. Since the audits are continuous for a year at a time the facility will be able to quickly see declines or improvements in documentation practices. 

Another way to ensure your medical record measures up is to review the forms utilized. Ask yourself these questions:

• Do these forms provide staff with useful information?
• Are there any redundant documentation practices? 

The West Virginia Health Care Association (WVHCA) Survey Task Force committee recently took a very close look at Medical Record documentation practices and decided to tackle these very questions. The Task force of WVHCA began this project over two years ago with a goal to streamline paperwork, reduce redundancy and present the Model Medical Record to their members ensuring documentation requirements for MDS reporting, Federal/State regulations and reimbursement were met. 

The task force consisted of representatives from the WVHCA, facility administrators, representatives from corporate chains along with private owners, social workers, nurses, activity professionals, Registered Dieticians, Registered Health Information Managers, and Pharmacists along with representatives from the West Virginia Medicaid Office and Office of Facility Licensure and Certification. After two years of working together, the model record will be presented to the WVHCA members at the May convention. The task force has been piloting the Model Medical Record in five facilities and has received positive feedback from them.  

These are just a few ways to ensure your medical records measure up to today’s consumer expectations. I highly recommend we all take a very serious look at the medical record practices because now more than ever we cannot afford to fall short in this area. 

Tamela S. McQuiston, RHIT, RAC-C
President Paramedical Consultants, LLC

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