Diagnostic tests, x-rays--reports for all tests and x-rays ordered filed in the chart.

Documentation of various types of treatment.

Operative permit

Report of Operation

Pathology report, if appropriate

Copies of routine physical examinations maintained in record

Obstetrical history maintained and sent to hospital at proper time?

Reports of CHS medical care

Hospitalization summaries by referral hospital or physician.

QUANTITATIVE ANALYSIS OF INPATIENT RECORDS 

Definition.

Quantitative Analysis is a review of prescribed areas of the medical record for identifying specific deficiencies in recording to ensure that it is complete, accurate, and current. Items that do not meet the criteria should be noted on a check-off sheet for future review and processing by the responsible staff--medical, dental, nursing, and allied health providers.

Purpose.

The purpose of quantitative analysis is primarily to identify obvious and routine omissions that can easily be corrected in the normal course of the hospital's procedures. This procedure makes the medical record more complete for reference in continuing patient care; for protecting the legal interests of the patient, physician, and hospital; and for meeting licensing, accrediting, and certifying requirements.

Availability of Records.

The first necessary step in discharge analysis is verification that a record has been received in the Medical Record Department for each patient discharged. Verification is made through Admission and Discharge Listings.

It is important that the medical record be made available immediately following discharge (within 1 workday), to facilitate its safekeeping. Once a patient has been discharged, the mechanism for preservation of the medical record at the nurses station is interrupted and the chances for loss of record control increase.

Timeliness of Documentation and Review.

It is necessary that the component parts of the medical record be recorded as soon as possible after diagnostic procedure, care, or treatment of the patient has occurred, and the information is summarized immediately following discharge in order to ensure accuracy and credibility.

NOTE: The legal value of documentation is inversely proportional to the length of time between an event and the documentation of that event.

It is extremely important that the initial review of a medical record be made no later than the first workday following discharge of the patient in order to facilitate meeting accreditation requirements, and third party billing requirements, and in order to avoid situations where corrections are required of personnel who are no longer employed by the facility.

Arrangement of Inpatient Medical Record.

While the patient is hospitalized, the medical record forms of the current admission are arranged in a manner prescribed by the medical and nursing staff.

Upon discharge from the hospital, the medical record is rearranged for permanent filing in accordance with the standardized format approved by the IHS. It is necessary for the filing sequence for medical records to be consistent in order to facilitate consultation and review activities.

Record Deficiency Forms.

While analyzing the medical record, all deficiencies shall be noted on the deficiency form.

This form-is retained in the medical record until the medical record has been determined to be complete. At that time the form is destroyed unless retained for study purposes. If retained, the form shall be maintained in a locked file and is never considered a part of the medical record.

Analysis of the Inpatient Record.

Throughout review of the record, be alert to the following pertinent information about a chart in order to verify the patient identity on each form:

Name of Patient

Sex

Date of Birth

Diagnosis and/or condition

These factors will assist in determining discrepancies within the medical record; for example, a six year old male with an incorrectly filed pathological report indicating Hypertrophied Prostate.

It is essential that identification of the patient be noted on each page of the record.  Any lack thereof should be detected immediately during preliminary review of the patient's medical record in the Medical Record Department.

Appropriate signatures and/or notations must be authenticated for each page.

Review of Component Parts of the Record.

Review inpatient record for:

Completion of sociological data on each admission to hospital, including sex and age or other information which might be of significance.

Verification that the correct unit number is indicated, that the most recent admission is with folder, that other parts of the record are present, and that data is consistent between component parts.

Completion of all medical data pertinent to the record, with particular note that infections, complications, cause of death, and/or trauma information are properly recorded.

Correlation of medical data: Diagnosis to cover conditions within the record, diagnosis for each operative procedure, final diagnosis to coincide with the pathological diagnosis, and final diagnosis stated in appropriate terminology.

History: Signature of physician or, provider taking and writing history, with countersignature of responsible physician if appropriate.

Physical examination: Statements of observations and findings without use of terms "negative" and "normal".

Signature of the individual performing and writing physical examination, and countersignature of the physician if appropriate.

NOTE: One signature or countersignature may be sufficient for both history and physical examination if the same physician is responsible for both documents and if this practice is allowed in the Medical Staff Bylaws and Rules.

Progress Notes: Special treatments performed in patient room or elsewhere, necessitating the use of other than progress note forms; for example, biopsy and endoscopic examinations.

In case of death, note by physician pronouncing patient-dead.

Signature of author and date of each progress note.

Time of progress note on the following: anesthesia notes, notes relative to critical events (codes etc.), and-notes pronouncing the patient dead.

Doctors Orders: Orders signed or countersigned, if appropriate.

Orders for tests and x-rays--compare with chart to determine that reports of the tests ordered are filed in the chart.

Orders for condition indicating a complication (e.g., an order for a wound culture in a clean case). Check for:

Verification in progress notes indicating final diagnosis.

Discharge order written and signed by physician, or presence of Release from Responsibility Form.

Laboratory tests and pathology reports: Laboratory tests adequately recorded.

Any test suggesting complications (e.g., positive wound culture in clean surgical case).

Other diagnostic tests indicated (e.g., x-ray report in fracture cases).

Pathological report, any normal tissue removed. Correlation of pathology report with final diagnosis and with statement of tissue removal from operative report.

 Reports related to, procedures performed in operating room.

Consultation:  Completion of all component parts

Blood transfusions:  A form for each 500 cc. given.

Completion of all component parts.

Appropriate signatures.

Signed consent of patient.

Surgical Unit Documentation: Operative permit properly signed for each operation (i.e., bronchoscopy or cystoscopy, any procedure performed in operating room, or any administration of a general anesthesia).

In hospitals, a Preanesthetic Summary recorded for all major. surgery.

Anesthetic record adequately completed for each operation.

Recordings of postanesthetic visits indicating presence or absence of anesthesia-related complications,

Operative report containing all component parts for each operation.

Pathology report for surgery where tissue is removed unless procedure is excluded by medical staff. Tissue removal involved in Tubal Ligation is usually excluded from requirement for tissue examination.

Consultation report if surgeon is other than attending physician.

Operative report is accurate. (Transcribed title of all procedures present, with accurate and complete anatomical specifications)

Presence of signed and completed consent.

Radiology:  Original copy, with signature of radiologist

Special Reports: 

Electrocardiogram (ECG) requires appropriate segments of tracing and report with signature of physician making interpretation.

Autopsy--Need authorization and report if autopsy was performed.

QUALITATIVE ANALYSIS OF MEDICAL RECORDS

Definition.

Qualitative analysis is a review of medical record entries for inconsistencies and omissions which may signify that the medical record is inaccurate or incomplete. Such an analysis requires a knowledge of medical terminology, anatomy and physiology, fundamentals of disease processes, medical record content, and the standards of licensing, accrediting, and certifying agencies.  It is usually performed by a qualified medical record practitioner.

Purpose.

As is true of quantitative analysis, the purposes of qualitative analysis include making the medical record complete for reference in patient care, protecting legal interests, and meeting regulatory requirements. Because it is more in-depth than quantitative analysis, however, it serves these purposes more fully; and it also contributes background or supporting information for quality improvement and risk management activities. Qualitative analysis also assists in diagnosis and procedure-coding specificity and sequencing which is important for ongoing medical research, administrative studies, and reimbursement.

The components of qualitative analysis include a review of the medical record content (assuming the completion of quantitative analysis) for:

Complete and consistent recording of diagnostic statements.

Consistency in entries by all health care providers.

Description and justification for the course of the patient's hospitalization.

Recording of all necessary instances of informed consents.

Application of good documentation practices.

Occurrence of a potentially compensable event.

Delinquent medical record rate.

Examples of qualitative analysis are:

Review of records for indication of post-op wound infection; review of records for indication of postpartum infection; review of physical exam for essential data items such as:

Pelvic and rectal exam prior to abdominal surgery and quality of documentation of findings;

Review of blood and component use against criteria established by the Tissue and Transfusion Committee;

Review of documentation items identified by, the medical staff or medical staff body involved in quality review activities;

Review of potentially compensable events; and

Review of Pathology Reports against Operative Reports and Diagnoses to ensure that there is compatibility and consistency.

Qualitative analysis is not something that can be undertaken lightly. It requires an in-depth understanding of medical record science and management. This activity must be performed or directly supervised by a credentialed medical record practitioner. Further, that individual should be experienced in record analysis and quality review activities.

Qualitative analysis may be done routinely or on a sampling basis depending on facility needs and staffing patterns. However, at a minimum the review of results should be a major part of the Medical Record Committee activity.