3 Ways to Ensure Completion of Medical Records

Timely and accurate completion of medical records is essential to ensuring great quality of care, as even the smallest inconsistency or miscommunication of patient information could mean negative consequences for the patient. Here are three ways ASCs can ensure medical records are completed in a timely and accurate fashion.

1. Hire a staff member to track medical records. Elaine Thomas, administrator at St. Francis Mooresville (Ind.) Surgery Center, says the first step taken at her ASC to ensure physicians were signing orders in patients' medical records was appoint a single staff member to track completion on a daily basis. All patient medical records handled in a day are collected and meticulously scanned for completion, with an emphasis on ensuring physicians signed all orders. St. Francis Mooresville's clinical staff requests signatures when they know a signature is needed, both on the front-end as well as retroactively, she says.

"For example, sometimes physicians will have left the ASC after seeing a patient without signing an order or authorization for his or her pain medications," Ms. Thomas says. "I want to make sure our ASC [is following up with this], so I have a staff member who has taken this upon herself to track physician signatures in medical records."

2. Regularly conduct chart audits. Chart audits are another method of monitoring and tracking how often physicians are complying with the standard of accurate completion of medical records. Ms. Thomas says her surgery center consults a third-party company to do the chart audits. "Since we started doing these audits, there has been a huge improvement on physician signatures in medical records," she says. "The audits have helped increase awareness with both the clinical staff and physicians."

3. Invest in health information technology solutions. ASCs can reap a multitude of benefits from implementing health IT systems. Not only are healthcare providers eligible to receive incentives for meaningful use of electronic health records, but many industry experts would agree that the huge front-end investments will pay off over time in the form of improved patient care, interoperability with other providers as well as streamlined processes, such as complete medical documentation.

"Our receptionist used to have to take all our medical records to make sure they were complete and enter updates into the computer, and there can be an integrity issue if she's unsure what the physician is documenting in that record," says Sarah Sterling, business administrator at Post Street Surgery Center in San Francisco. "Now we use tablets with drop-down boxes, check boxes or fields where nurses can type in the information, so now medical records are more legible and there's no need to figure out what the physician or nurse wrote. Our EMR system is also set up to have required fields on a form, so users cannot move forward until they fill out everything that's required."

Thank you to Healthcare Facilities Accreditation Program, which accredited St. Francis Mooresville Surgery Center, for arranging this article.

Learn more about HFAP.

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