Looking Over Your Shoulder in Healthcare: Chart Audits

Part 2

Carolyn Buppert, NP, JD

Disclosures

December 08, 2011

In This Article

Accrediting Organizations Look at Records, Too

One of the Joint Commission (TJC) standards is "ongoing review of medical records at the point of care, based on the following indicators: presence, timeliness, legibility (whether handwritten or printed), accuracy, authentication, and completeness of data and information."[7] Furthermore, when a sentinel event (an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof) occurs, TJC expects hospitals to conduct a root cause analysis, answering such questions as:

  • What happened (details)?

  • Why did it happen?

    • What are the steps in the process, as designed?

  • What were the most proximate factors?

    • What steps were involved in the event?

    • What human factors were relevant to the outcome?

    • How did the equipment performance affect the outcome?

    • What factors directly affected the outcome?

  • If the event was attributable to "uncontrollable external factors," were the factors truly beyond the organization's control?

  • To what degree is all necessary information available when needed? Was the information complete? Was it ambiguous?

  • To what degree is communication among participants adequate?

In its accreditation process, TJC reviews organizations' activities in response to sentinel events.

An analysis of TJC foci showed that the following issues are worth addressing internally and well before accreditation visits:

  • Legibility of documentation;

  • Appropriate use of abbreviations;

  • Adequacy of documentation of initial patient assessment (nursing);

  • Adequacy of documentation of patient and family education; and

  • Adequacy of documentation of necessity of restraints.

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