MEDICAL RECORDS                                                                                           35-02-007

CORRECTION OF DEFICIENCIES

POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires each of the New Jersey Veterans Memorial Homes (VMH) to implement a process of accountability that ensures deficiencies identified in a medical record are corrected.

PURPOSE.

This policy and procedure serves to ensure that each of the New Jersey Veterans Memorial Homes implements a “check and balance” process intended to ensure deficiencies in a medical record are corrected in a timely manner, and that medical records are monitored for continued compliance.

DEFINITIONS.

Deficiency - the absence of a required element needed to meet a pre-established standard.

PROCEDURE.

1. Correction of deficiencies for active Medical Records

1. The Monthly Chart Audit Checklist is used by the Medical Records Supervisor or designee to document deficiencies.

2. A memo will be sent within seven (7) days of the noted deficiency to the liable Department Head indicating deficiencies that need to be corrected.  A copy of the memo will be maintained in the Medical Records Office.  The date the deficiency was noted and the date the memo was sent is to be documented on the resident's index card in the "Tickler File."

3. Deficient charts will be reviewed within seven (7) days to ensure that all deficiencies have been properly corrected.

4. The resident shall have the right to attach a brief comment or statement to his or her medical record after completion of the medical record.

2. Correction of deficiencies for Medical Records of discharged or deceased residents

1. Refer to the procedure for "Completion of Medical Records", 35-02-008.

Revised:   July 2007
Revised:   April 2010

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