MEDICAL RECORDS                                                                                           35-02-006

AUDITING MEDICAL RECORDS

POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires each of the New Jersey Veterans Memorial Homes (VMH) to implement a self-analysis system intended primarily for the identification of obvious and routine omissions, patterns of poor documentation practices, and possible liable events that can be easily corrected in the Medical Records.

PURPOSE.

This policy and procedure serves to ensure that each of the New Jersey Veterans Memorial Homes implements a quantitative and qualitative self-inspection process for Medical Records that serves to identify correctable deficiencies, patterns of poor documentation, and possible liable events.

DEFINITIONS.

Auditing - refers to the quantitative and qualitative analysis of Medical Records.

Deficiency - the absence of a required element needed to assure compliance with licensing and regulatory agency standards.

Quantitative Analysis - a review of prescribed areas of the Medical Record for identifying     
specific deficiencies in recording.

Qualitative Analysis - a review of Medical Record entries for documentation practices that may
indicate the Medical Record is inaccurate or incomplete.

PROCEDURE.

The following list outlines the steps for auditing Medical Records based on a quantitative and qualitative analysis approach.  This process is intended to assure the Medical Record is complete for reference in continuing resident care; for the protection of the legal interest of the resident, the service provider, and the facility; and to ensure deficiencies identified are corrected in compliance with all regulatory requirements.

1. A 10% random sample of all Medical Records shall be audited monthly by the Medical Records Supervisor or designee.

2. A Monthly Chart Audit Checklist is maintained for every medical record.  The Checklist is a criteria-based monitoring tool used to ensure that a specific standard is always met.  A check mark is placed next to items that meet the standard.  An “x” (in red ink) is placed next to each item that does not meet the standard.

3. A list of deficiencies that need to be corrected is sent to the responsible Department Head within seven days of the audit.

4. The Medical Records Supervisor regularly checks to verify completion of deficiencies.  Items still deficient are reported to the appropriate Department Head.

Revised:   April 2010

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