Hospital Accreditation
Making Your Medical Records Survey Ready
Posted by
on 9/18/2018 10:00:00 AM
One of the most challenging aspects of a survey is demonstrating that your medical record documentation meets accreditation and certification standards. Weeks and months of effort are swept away in an instant when practitioners fail to appropriately document the care they provide.
Making your medical records “survey ready” is a daunting – but not impossible challenge. Here are some tried and true tips to help you be successful.
- Have a Regulatory Expert on Your EMR Build Team
Our organization has surveyed a multitude of electronic medical record (EMR) platforms over the years. It’s amazing how often the design of an EMR fails to meet even the most basic regulatory requirements. Having someone on the build-team that understands the Medicare Conditions of Participation and the standards of your accreditor can help your organization design a compliant medical record from the outset.
- Create Cheat Sheets to Navigate the EMR
Often EMR’s look and operate differently when entering data in real time, versus retrieving archived data. Clinicians often have difficulty retrieving information in open medical records during a survey. Having simple directions on how to retrieve key documentation can help your staff have a successful survey experience.
- Timely Review is the Name of the Game
Think about this. If surveyors are auditing your open medical records in real time, shouldn’t you be doing the same thing? For the most part, retrospective review of medical records is not an effective strategy. Move to concurrent – and even prospective – review to identify lapses in documentation in a timely manner.
- Establish Strategic Choke Points
I’m not talking about choking the practitioner who botched his or her documentation (although the sentiment is understandable). A “choke point” is a temporary halt to a non-emergent patient’s progression of care to assure that all required documentation is present in the medical record before the patient’s moves to the next phase of care.
- Target Individual Documentation Behaviors
Aggregate data does not change individual behavior. But changes to individual behavior can aggregate to a compliant medical record. The secret is to identify the specific practitioners who are non-compliant and provide them with the feedback and support necessary to improve their documentation practices. Consider using prevalence studies rather than a “hit or miss” approach such as a random sampling of medical records.
While there is no magic bullet, these and other common sense approaches can go a long way towards making your medical records survey ready every day.
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About the Author
Richard Curtis RN, MS, HACP
RN, MS, HACP
Richard (Rick) Curtis is the Chief Executive Officer for CIHQ. Rick is nationally recognized as an expert on the Medicare Conditions of Participation and the CMS Certification & Survey Process. As CEO, he successfully guided CIHQ in becoming the nation's 4th CMS approved deeming authority for acute care hospitals.
Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.
Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.
Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.
Accreditation
