As a new home health nurse (many years ago), I was assigned a few clinical record reviews to perform on the charts of my more experienced co-worker. I still remember this because I learned so much about the correct way to document as well as some helpful tips on how to teach my patients to better care for themselves at home.
Clinical record review is required in the Conditions of Participation and has been cited in three of five re-certification surveys second quarter. The issues commonly cited were a lack of reviews done at least quarterly and not including disciplines representative of the visits provided. Clinical record reviews must be done by all disciplines being utilized at your agency. Since this needs to be evident, it is very important the associates performing the reviews indicate their name and credentials on the review form.
We all want to have outstanding, positive results on any review but Clinical Record Review is an opportunity for an agency to detect and correct problems before a state surveyor finds them. Reviewers should be taught how to review the charts as well as the importance of their honest review of the chart contents. If a surveyor finds a problem, they will often have a more positive perception of the agency when you can show them you are aware of the problem and have implemented a process improvement plan.
It’s easy to think of Clinical Record Review as one more mundane thing we have to do but it’s really a valuable opportunity.
Article submitted by: Lori Velko, Director of Compliance