The post JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Committee & TOR presented the MMRC. Let us not be confused with the role of a Medical Records Committee (MRC).
Most hospitals also have a MRC, which will be already familiar with medical records and performs activities similar to Medical Records Review (MRR), such as analysing medical records for completeness and timeliness.
Because a MRC with ongoing records review oversight also conducts similar exercises in MMR, even HIM/MR staff and other staff in both the MMRC and MRC might be agitated why there is duplication in MMR activities.
Allow me to briefly present a protocol for a MRC with ongoing records review oversight which will be different from that of a MMRC as follows:
Purpose
The MRC will have oversight for the hospital’s ongoing records review program(pre- and post-JCI survey), the review and approval of forms and format for the medical record, including electronic applications.
Maybe the MRC should discuss at its meetings if they need to discontinue their ongoing record review program during the accrediting phase, to prevent work fatigue.
Scope
All types of medical records and related functions, including paper based and electronic.
Responsibilities
Coordination and oversight of the hospital’s ongoing records review program includes:
- Establishing the calendar for reviews
- Assisting with topic and indicator selection
- Establishing focused reviews
- Analysing data from reviews, and taking action as soon as appropriate
- Conducting point of care reviews using the tracer methodology(more on this in later posts)
- Reporting to appropriate hospital and medical staff committees
- Review and approval of forms and format for the medical record, including electronic applications
- Other duties as relate to the documentation, use, and storage of medical records
Membership
Membership should include doctors, nurses, other clinical care providers, HIM managers and others identified by the committee. A clinician in good standing on the medical staff would be most suitable to chair the committee.
Meetings
Meetings can be scheduled to occur monthly.
Reporting
The committee will report regularly (example, quarterly) to the medical executive committee.
Statement of confidentiality
Members of the committee will honor patients’ rights to privacy with respect to information in the medical records. All reports will be free of patient identifiers.
I hope with this post, the differentiation between MRRC and MRC is clear already!
