JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol, Medical Records Review Tool

To continue on MMR, I shall discuss a little about the MMR tool form (the form will open in a new tab of your current window), for a start.

I have modified the form with some features that are not available on the form presented in the Hospital Survey Process Guide. I made the modifications based on my experiences leading the team in the MMR process. I think the following changes in the form are to facilitate a successful MMR process:

  • a header section with the hospital’s name printed, and also a box to enter the review date, on all 3 pages of the form
  • the right-most column, the column TOTAL Y/N,  is divided into two columns, one for Y and the other for N
  • standard ACC.3.2 is on one page, on page 3
  • a remarks box, only on page 3
  • a box for the reviewers name and another box for the reviewer’s signature, only on page 3
  • a footer section for all the 3 pages – the page number insert, since the original form does not have a page number

In the form found in the guide, the TOTAL column(the right-most column) was only one column. So after I  counted the number of Ys and Ns for each row, my entry in this column showed as  the number of Ys and Ns separated by a forward slash. For example if I entered “3/5” in this column to denote a count of 3 Ys and 5 Ns. I found it messy and mistake prone when  I  picked-up this entry(this “3/5” way of recording) during data entry into a computer. Thus I modified the form by adding 2 columns under the TOTAL column, i.e. one for Y and another for N, and in doing so I found it easier and mistake free during data entry into the computer..This is an experience you get when you do the data entry yourself in the early stages of testing out the MMR form.

I think the remarks box is important for the reviewer to enter remarks, which was otherwise written haphazardly, when the form found in the guide was used as-is

The form also did not have a place to write the reviewer’s name and his / her signature, I thought these two modifications were important for tracing the form’s author.

The footer section with page numbers is helpful in sorting the forms during data entry into a computer.

These are some of the things I made to the MMRT form. I shall add some tips and guidance at a later date.

There is nothing permanent except change
Diogenes Laërtius in Lives of the Philosophers Book IX, section 8

1 thought on “JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol, Medical Records Review Tool

  1. Please take note that I have updated the MMR Tool Form with changes to the Documentation Requirement ‘Screening for pain on admission’which is Standard AOP.1.7 and not Standard AOP.1.8.2. Also for the Documentation Requirement ‘Written Surgical Report’, which is Standard ASC.7.2 and not Standard ASC.7.3.

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