We all know that proper documentation in the patient’s medical record is a key requirement if your hospital wishes to have a successful survey. While hospitals can assure that their medical record (whether paper or electronic) is designed to be compliant to regulations and accreditation standards, assuring that staff and physicians document appropriately is an entirely different matter.
Hospitals take a variety of approaches to assure that documentation in a patient’s medical record will pass muster during a survey. Chart audits, prevalence studies, and concurrent monitoring are just a few. But there is one strategy that can be particularly effective – and yet is seldom utilized; namely shift report on the inpatient care units!
Every care unit has some sort of hand-off process between clinicians as one ends his or her shift, and another starts. Most frequently, this involves a face-to-face conversation between the two clinicians discussing the patient’s status, care needs, etc. It’s the perfect opportunity to review the patient’s medical record to assure that all critically necessary documentation has been entered by the off-going clinician before responsibility is handed off to the on-coming provider.
For example, insufficient documentation of monitoring a patient while in restraint will almost always result in a deficiency – usually at a condition-level.
During shift report have both clinicians validate that documentation of patient monitoring by the off-going clinician has been completed. If not, the clinician can enter the information into the record then and there.
Along the same lines, if a patient has been having pain issues during a shift, the report hand-off can be a time where the record is reviewed to assure that pain assessments and reassessments were documented.
Hospitals need to be strategic in using shift report to check on medical record documentation. It will take time and folks will want to be careful to not bog down the process in detailed reviews. But if strategically applied, using shift report can be an effective strategy in assuring that medical records are survey ready.