Health Information Technologies and Processes

Analyzing the Medical Record

  • 1.  Analyzing the Medical Record

    Posted 12-12-2019 10:59
    I would like to know if anyone has an updated check list for analyzing medical records. The reason I am asking this, is because things have changed so much in the last few years that now we have so many other things to look for such as the "Moon Consent" form. In my department, we analyze all medical records to make sure all orders and results are available as well as proper HP, DS, OP and the list goes on and on, however; I am always worried that there is something we should be checking for that we are not doing. Any insight on this will be greatly appreciated.

    Thank you,

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    Mayra Allemond
    Him Director
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  • 2.  RE: Analyzing the Medical Record

    Posted 12-12-2019 11:16

    Hi Mayra,


    We have significantly narrowed down what we audit. We only analyze for a missing discharge/expiration summary, operative report, reason for leaving AMA, cancer staging form, and final diagnosis. My documentation specialist picks up other items during her auditing such as a missing H&P, missing or late H&P updates, documentation content that require certain elements, etc. Hope this helps.


    Thanks,

    Karla

     






  • 3.  RE: Analyzing the Medical Record

    Posted 12-12-2019 15:52
    Thank you so much for your quick response Karla!

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    Mayra Allemond
    Him Director
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  • 4.  RE: Analyzing the Medical Record

    Posted 12-13-2019 08:32

    No problem!