Health Information Technologies and Processes

Benchmarking - please answer what you can

  • 1.  Benchmarking - please answer what you can

    Posted 04-28-2020 12:18

    We are reviewing our medical staff activities and the role of our Clinical Documentation Quality Committee and would like to get your perspective on how your medical staff is meeting regulatory standards related to medical records in an electronic world.    

     Taking into consideration the Medical Staff is responsible for the quality of medical care provided to its patients in a hospital; shall participate in medical record review and report to MEC & BOT; review performance data (timeliness and legibility); review & analyze medical records for adequacy, content, authentication, VO/TO and required documentation; have a process for completion to include timeframes; and required documentation. 

     

    • What EMR do you use? 
    • How does your medical staff meet the requirement to review and analyze medical records for adequacy, timeliness, legibility & authentication, content and compliance with required documentation? 
    • Do you have a medical staff committee defined in your medical staff governing documents that focuses on medical records? 
      • If so, what are the duties and responsibilities? 
    • Does your medical staff or advanced practice professionals review and analyze medical records for adequacy of documentation and compliance with approved forms, power plans and forms?
      • If so, how is this accomplished? 
      • Who administratively facilitates the reviews? 
      • Do you engage
    • How do you manage medical staff review and input on new/revised EMR forms and order sets (power plans), power forms and other document types in EMR? 
      • Do you have an efficient & effective method to review, test the electronic work flow and gain Medical Staff input through the MEC or other committee structure?
      • How do you define what needs medical staff approval?   

     

    • How do you manage medical record delinquencies? 
    • Is there a consistent process for Hospital and Ambulatory chart deficiencies?
    • Who is administratively responsible for the delinquency process and communication to providers? 
    • Is your process automated? 
    • Do you "suspend" providers or limit their ability to admit/register patients? 
    • What are the provider ramifications for delinquency?

     

    Thank you for your time.  It is greatly appreciated! 



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    Sherri Simpson
    Manager, Him
    Charleston Area Medical Center
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