title: Best practices in record completion.
abstract: Completion of hospital and office (clinic) medical records is one of the least popular of clinicians' duties. Adherence to Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements and submission of hospital and provider bills to insurers and patients, however, are predicated on patient charts being completed and signed in a timely manner. This article details the rules and regulations that many institutions impose on providers to assure that records are up to date. It also discusses the carrot-and-stick approaches that are frequently used to assure compliance.
authors.affiliation: Precyse Solutions, USA. cdoyon@precysesolutions.com
authors.forename: Cindy
authors.initials: C
authors.lastname: Doyon
mesh_terms: D019985:Benchmarking; D004282:Documentation / Q000592:standards*; D006801:Humans; D007344:Insurance Claim Reporting; D007591:Joint Commission on Accreditation of Healthcare Organizations; D008499:Medical Records / Q000592:standards*; D008500:Medical Records Department, Hospital / Q000592:standards*; D008505:Medical Staff, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D010350:Patient Credit and Collection; D014481:United States