Health Information Technologies and Processes

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!! 

    Hayden Zenner
    Lake Region Healthcare Corp

  • 2.  RE: Joint Commission Audits/Reviews

    Posted 06-12-2019 08:37

    Here is information from our Performance Excellence Dept:


    I run a report every month by "admitting provider" for Ambulatory Surgery, Inpatient and Observation Patients.   Then I randomly select 10% of each provider to review, if the provider has less than 10 I random pick 2.  Once the Medical Record Review is completed I send letters out to the providers telling them what they indicators they fell out on.  This information is then shared by specialty at our Medical Staff Section Meetings and PQRC Quarterly.  The below statement is what we include in our provider orientation.


    In an effort to provide World Class care for our patients in a safe environment and to meet Joint Commission requirements1, we monitor the medical record for timeliness, completeness, and accuracy.  This helps to ensure that information is readily available for those participating in the patients care.  The elements monitored are as follow:


    ·         Final diagnosis recorded in full

    ·         Clinical Summary dictated w/in 7 days of discharge and all elements of the CS are on the chart

    ·         History and Physical dictated within 24 hours of admission and all elements of the H&P are on the chart

    ·         History and Physical completed within 30 days prior to prior surgery and updated 24 hours prior to procedure  

    ·         Consultation rendered w/in 24 hours of request

    ·         Consultation dictated w/in 48 hours of request

    ·         Operative Report is dictated w/in 24 hours of surgery

    ·         Pre-Anesthesia note includes:  Date, Time, and Signature

    ·         Post-Anesthesia note includes:  Date, Time, and Signature and completed within 48 hours of procedure

    ·         Brief Op Note completed prior to next level of care

    ·         Inpatient Daily progress note written by Attending Physician or Designee

    ·         "Do Not Use" abbreviations not used. 

    ·         Chart legible

    ·         All entries dated and timed

    ·         Consent to treatment filled out correctly



    Wendy Mangin, MS, RHIA

    Executive Project Director – Regulatory Compliance/Privacy Officer


    Good Samaritan 

    520 S. Seventh St. | Vincennes, Indiana | 47591

    Hospital: 812.882.5220 | Direct: 812.885.3487 

    Fax: 812.885.3912 | 

    b326b5f8d23cd1e0f18df4c9265416f7  images   Website | Videos | News | Events