June 2, 2000

Approximately 45 members of Patient Care Services (PCS) gathered recently for a training session on medical record standards. Joan Fitzmaurice, RN, PhD, director of Quality for PCS, and Deborah Adair, MPH, MS, RHIA, director of Health Information Services, led the session, which was meant to help MGHers prepare for the medical record review portion of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey that will take place this fall.

According to Fitzmaurice, the upcoming medical record review will differ from previous surveys in that medical records will be randomly selected by surveyors for review instead of selecting predetermined records, the survey time will be twice as long, and more records will be chosen for review on each unit. Each participant of the training session brought in samples of medical records and used a record review tool to assess the completeness of his or her own records.

"Our goal in providing this kind of training is to review the JCAHO standards that are expected for completing medical record information and to clarify any questions employees might have," says Fitzmaurice. "We also hope to use the information we gathered from using the assessment tool as performance improvement data for the ongoing record review."

According to Adair, JCAHO requires medical records to be complete, accurate and timely to comply with specific guidelines. In addition, JCAHO also requires health care organizations to implement record review processes and take actions to improve documentation as necessary.

For more information about medical record reviews, call Adair at 4-0208.