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Knowing what constitutes medical record completeness in the eyes of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, doesn’t have to be a guessing game. The organization recently released its "2001 Medical Record Review Summary Sheet," which outlines 19 items that the Joint Commission requires to be included in an ongoing review of medical records. The sheet also includes ways to document any performance improvement initiatives that providers launch to address their findings.
For a provider to be compliant with Joint Commission standards, the medical record review must be ongoing, with audits conducted on a quarterly or annual basis. If audits are conducted on a quarterly basis, the quarterly results should be made available to the Joint Commission, and activities to address improvement should be evident. If the audits are conducted annually, the providers would need to report data from the previous two years to demonstrate process improvement.
Joint Commission surveyors will use the form to orient them to the scope of the medical record review activities of the provider for the 12 months prior to the survey. "We are using [the sheet] as a tool to help us evaluate the organization’s activities and compliance with Joint Commission standards," says Janet McIntyre, spokeswoman for the Joint Commission. The form also lets providers know what the review process is going to be, she adds.
The completed form should be attached to the medical record review material supplied for the Document Review Session, which is a survey activity designed to prepare and orient surveyors for subsequent survey activities. The medical record review material should include reports or minutes for the 12 months prior to the survey of the group responsible for the review of medical records.