Are we overwhelming physicians with medical record review?
The importance of the medical record as a communication tool and as evidence of treatment demands the systematic evaluation of record adequacy. In fact, standards of the Joint Commission on Accreditation of Hospitals require such a review. Yet in some hospitals, medical record review is perceived as nothing more than a paper exercise. What might medical record practitioners do to minimize the time required for an effective record review? The author suggests methods proven successful at a small hospital in Oregon.
D004282:Documentation / Q000592:standards; D006743:Hospital Bed Capacity, under 100; D007591:Joint Commission on Accreditation of Healthcare Organizations; D008499:Medical Records / Q000592:standards*; D009922:Oregon; D010380:Peer Review / Q000379:methods*; D011367:Professional Staff Committees / Q000458:organization & administration*; D013997:Time Factors