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Clinical Record Review


If you are like most agencies, your nurses are wearing more than one hat, as a favorite DON used to say. Nurses in the office performing duties as QA nurses will also pick up the phone and take orders or go admit a patient when the agency is running short of nurses. A host of different staff members may take part in QA activities when survey is drawing near. No QA at all may get done when the agency is extremely short staffed or dealing with another project such as an audit.

The flexibility demonstrated by most nurses in home health is amazing. We wouldn’t make it without this heroic ability to change gears and move seamlessly between assignments. And yet, this familiar pattern of staffing does have its drawbacks.

Nurses who work the floor in the hospital are almost never called to review charts. QA is kept separate from the staff for a very valid reason. First of all, once a nurse has participated in the care of a patient, QA of the clinical record becomes challenging. It is too easy to read between the lines. An order that was taken from a physician but never transcribed may be overlooked when reviewing the chart because the nurse reviewer remembers writing the order! Big gaps in the clinical record such as no therapy for patient in need may not stand out to a nurse who knows that the patient had therapy on a prior admission or has refused.

These sorts of errors are most easily found by a person who has no prior experience with the patient. Ideally, you would want to hire a consultant, preferably me, to review your clinical records periodically but even we understand that an agency’s budget doesn’t always allow for it. Don’t worry, you are not doomed!

If your agency has more than one location such as a parent or a branch or a sister location, the answer is easy. Trade out a nurse a few times a year and have someone who is relatively unfamiliar with the patients review the records. Most agencies hire PRN nurses for admissions and visits when the agency is very short staffed. By looking for QA experience in these nurses prior to hiring them or signing a contract will ensure that you have a fresh set of eyes to go over your clinical records.

When these reviews do occur in anticipation of a survey, remember that there is precious little that can be done to correct some errors. By reviewing records 90 days prior to a survey and identifying trends, the problematic areas will ‘wash out’ of the clinical records before survey. Your regular staff will then know what to monitor and how to correct the issues.

Finally, would you rather answer to me or a state surveyor? By enlisting the help of someone who is only privy to the same information as a surveyor, you can identify problems long before the surveyor is asking for documentation that you don’t have!

 

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