Confidentiality, Privacy and Security

Joint Commission Audits/Reviews

  • 1.  Joint Commission Audits/Reviews

    Posted 06-11-2019 15:05

    I am wanting to reach out to the AHIMA community to try and gather some knowledge on how other facilities conduct reviews/audits for the Joint Commission, specifically, Chapter: Record of Care, Treatment, and Services (RC.01.04.01)

    Chapter Defined - RC.01.04.01: The hospital audits its medical records.

    The "Elements of Performance" states, "The hospital conducts an 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."


    I am searching for some insight to the following questions regarding this Chapter's review/audit process:

    1. How do other facilities define "ongoing"? Bi-Monthly, Monthly, quarterly, etc.
    2. When these reviews are conducted, are different specialties looked at every time, or are the charts chosen at random?
    3. Is the "point of care" defined by other facilities? If so, how is it defined?
    4. What volumes are pulled for these reviews by other facilities?

    Any insight to these questions will help us greatly!! 



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    Hayden Zenner
    Him-Coordinator
    Lake Region Healthcare Corp
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  • 2.  RE: Joint Commission Audits/Reviews

    Posted 24 days ago
    ​I am no longer at a JC facility but if my memory serves me well I believe it also says the review team should be inter-disciplinary.  Several years ago, when I was over that chapter, we had an inter-disciplinary team that consisted of mangers, clinical supervisor, etc. from every unit and clinic area in the hospital.  It was a large team but it meant that each person only had to review 3 charts a month.  The findings were presented at the Medical Records Committee that met once a month and from there the report rolled up to MEC.  If there was a noticeable area of concern, we would put together a plan of action to improved the results.

    I hope that is helpful.  Feel free to private message me for additional clarification.  I believe I still have an old old spreadsheet (review tool) I used.


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    DeAnn Tucker
    HIM Director & Privacy Officer
    Houston Physicians' Hospital
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