Here are six strategies to ensure your healthcare organization is maintaining accurate, complete, legible medical records, according to the latest Connection publication from the Accreditation Association for Ambulatory Health Care.
1. Ensure every clinical record has all the basic information. AAAHC surveyors often note missing information, including vital signs and dates and times on entries and orders.
2. Maintain standardized forms and processes. This includes formats for clinical records, the sequence of information, abbreviations and more.
3. Appoint one employee to oversee clinical records.
4. Choose a prominent and standardized location for logging information about allergies and sensitivities.
5. Make certain that all clinical records, including those for transfer or new patients, are updated accordingly.
6. Document all topics of discussion during every patient encounter.
Learn more about AAAHC.
1. Ensure every clinical record has all the basic information. AAAHC surveyors often note missing information, including vital signs and dates and times on entries and orders.
2. Maintain standardized forms and processes. This includes formats for clinical records, the sequence of information, abbreviations and more.
3. Appoint one employee to oversee clinical records.
4. Choose a prominent and standardized location for logging information about allergies and sensitivities.
5. Make certain that all clinical records, including those for transfer or new patients, are updated accordingly.
6. Document all topics of discussion during every patient encounter.
Learn more about AAAHC.