Medical records must provide an accurate account of the care provided
Medical records document the patient’s journey and must provide an accurate and comprehensive account of the care provided.
Recent findings during accreditation assessments and patient safety incident reviews uncovered several deficiencies in medical records documentation including:
- missing current physical exams, medical history, medication history, consent discussion, OSA, VTE and ARO screening
- missing nursing documentation in perioperative records
- missing nursing documentation in post-anesthesia care records
- inappropriate correction of documentation errors
Medical directors are reminded that medical record reviews must be conducted quarterly, include a cross-section of procedures and physicians, utilize an audit tool, be completed by an interdisciplinary team, and include a corrective action plan to address medical record deficiencies.