I have endeavored to make this protocol as general as possible and with no direct references to any organisation. This protocol is a framework you can modify and make it better to suit your organisation and needs.
In this post which is rather long, I shall avoid showing the relevant appendices on random tables, sampling technique example and the Medical Records Review Tool form, but they will appear separately in subsequent posts.
TITLE
Medical Records Review Protocol
SUMMARY
As part of a hospital’s performance improvement activities, hospitals regularly access(review) medical records based on a sample representing the practitioners providing care and the types of care provided for completeness, accuracy, and timeliness of the information they contain as required by the Joint Commission International(JCI) standards.
DESCRIPTION
Rationale
A medical record (patient clinical record as per Joint Commission International documentation) is a systematic documentation which serves as the business record for a patient encounter for every patient assessed or treated in a health care organisation as an inpatient, outpatient, or urgent care patient.
A medical record contains sufficient information of all health care services provided to a patient, and is a repository of information that includes demographic data(patient’s personal and social data) to identify the patient, as well as documentation to support diagnoses, justify the treatment, record treatment results, and an account of follow-up and final outcome to promote continuity of care among health care practitioners.
Statutes, accreditation standards, and professional associations frequently impose standards relating to the legibility, accuracy, and completeness of medical records. The Joint Commission International (JCI) standards of accreditation for hospitals require that data be collected in a timely, economic, and efficient manner using the degree of accuracy and completeness necessary for the data’s required use.
A hospital’s bylaws or policies normally require medical staff members to complete patient records within the specified time, and include punitive measures for those who fail to comply.
Usually, the Health Information Management(HIM) /Medical Records(MR) department head has the responsibility for making sure that records are completed within a specific time. Therefore, the HIM/MR department should establish procedures for notifying attending physicians when records are incomplete.
Objective(s)
A Medical Records Review(MMR) ensures the quality of a medical record is complete and accurate with the following objectives:
- to ensure only authorised individuals identified by organisational policy make entries in the medical record
- to create awareness of the importance of creating an accurate medical record and the legal and medical implications of failing to do so
- to enable healthcare professionals to plan and evaluate a patient’s treatment and to ensure the continuity of care among multiple providers
- to enable a healthcare provider to establish that a patient received adequate care.
METHODOLOGY
Design
The MMR is based on a sample representing the practitioners providing care and the types of care provided.
Subjects or participants
A sample of subjects is selected by selecting a total number of medical records randomly selected from a total number of medical records of the patients who visited during the current or past year to represent the population of practitioners providing care and the types of care provided.
Medical records of the expired patients are not included in the review.
Sample size
A convenience sample size of one hundred(100) medical records is drawn from a population size of 2 percent(%) of the total admissions or inpatients in one month, in a given year.
DATA MANAGEMENT AND ANALYSIS
Data Collection
Sampling Technique
- The discharge register listing (computerised) or the admissions register (manual) is used to collect the sample.
- A time period e.g for example the last calendar month is chosen.
- Simple random sampling using a five (5) digit random number table available in most statistics textbooks is used to select the sample.
- A data collection form with columns headers “No.”, “Subject No.”, “Random No.” and “MRN” is used to collect the 100 samples.
- “No.” is the number in the series, “Subject No.” is the subject number given to a selected sample, “Random No.” is the random number selected from the random table and “MRN” is the Medical Records Number.
- Each medical record selected using the random table is coded(given) a “Subject No.” beginning with “00” and ends with “99”, denoting the sample size of 100 medical records.
- From the 5 digit random table, choose the last two-digits from the left of the 5 digit number.
- Close your eyes and put your pen on one of the numbers in the random number table, for example XXX45. This will be your starting point and the first subject number.
- Record “45” in column labeled “Random No.” beside column labeled “Subject No.” along the first row labeled number “1” in column labeled “No.”, in the data collection form.
- Starting with the first selected number, choose a direction (up, down, left or right).
- Record the next 2 digit random numbers that appear in the table in their respective columns and rows, in the data collection form while moving in the chosen direction until you have selected 100 numbers which lie between 00 and 99.
- Any numbers which have already been selected are ignored.
- Using the data collection form and the listing or the register, choose the first entry with the last 2 digits of the MRN in the listing or register for the chosen period which corresponds to the first random number for subject number “00”. Enter the MRN in the “MRN” column in the data collection form.
- Likewise, check every consecutive entry in the listing or the register and enter each MRN in the “MRN” column in the data collection form for all entries with the last 2 digits of the MRN corresponding to the random numbers recorded in the data collection form.
- Count the number of entries in the listing or the register checked to collect the sample size(n=100) divided by the total number of discharges or admissions for the chosen month, to derive the percentage of the population sample size.
Medical Records Review Tool
A form is constructed with a listing of the JCI medical records documentation standards. A criteria “Yes”, “No” and “Not applicable (NA)” is used as the options in the Medical Records Review Tool form to access each standard listed.
Process
The data collection form is used by the HIM/MR Department to retrieve the selected medical records for the medical records review.
The review process is conducted on an arranged date and held periodically as stated in the Terms of Reference(ToR) of the Medical Records Review Committee.
The HIM/MR Department despatches the selected medical records for the medical records review to a predetermined area in the hospital premises for the review process.
The review process is conducted by the medical staff, nursing staff, and other relevant clinical professionals who are authorised to make entries in the patient record.
The MRRT form is used to review and score the selected medical records using the set criteria.
The MRRT forms are completed with reviewer details and signed, and collected by a Person-In-Charge.
Analysis
The MRRT forms are used to prepare a report.
The results of the review process are incorporated into the organisation’s quality oversight mechanism
ETHICAL CONSIDERATIONS
Members of the review process will honor patients’ rights to privacy with respect to information in the medical records. All reports will be free of patient identifiers.
Disclaimer:
I am no expert in statistical methods, however I have prepared this protocol based on my experiences and working knowledge on the Medical Records Review process similar to the one I had prepared as MCI Champion for the organisation I had worked for.
