How to Ensure Complete and Accurate Clinical Record Entries: Q&A With Dr. Jack Egnatinsky of AAAHC

Jack Egnatinsky, MD, is one of three medical directors at the Accreditation Association for Ambulatory Health Care and has been an active surveyor with the organization since 1996.

Q: Clinical record entries at ASCs are key to effective continuity of care. What are the biggest challenges in clinical record keeping?

Dr. Jack Egnatinsky: In my experience, one of the most common problems is that the medical history and physical examination of patients are incomplete. That information might be elsewhere in the chart, but depending on how the chart is organized and whether they have electronic or manual medical records, it's hard to find that information. Some of that information may include medication history, allergies and adverse reactions to medication or other things that may be used in a surgery center such as latex.

Another piece of information that is very often missing in clinical records is information after a procedure or operation. The requirement by CMS and AAAHC is to include a brief report of the procedure or the operation, such as what the procedure was, whether there were problems or complications or what the patient's condition was. What the surgeon typically does is dictate a detailed note of the procedure, but then that needs to be transcribed and by the time it's done, it may take a couple days [before it makes it into a medical record]. It needs to be done immediately after the procedure so that the information is there. The importance of that is so everyone taking care of that patient knows everything.

Q: So what can ASCs do to ensure clinical records are done completely and accurately?

Dr. Egnatinsky: It's a matter of regular review and enforcement of policy. Policies are almost always in place, but when you look at actual history and documentation, it's very often incomplete. ASCs have to do regular reviews of what is in clinical records and notify offending physicians that they are missing information that is either required by CMS or that particular ASC's own policies.

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