Alan Beyer, MD, of Orthopedic Surgery Center of Orange County in Newport Beach, Calif., explains how the surgery center ensures medical charts are completely and accurately filled out according to standards set by the Accreditation Association of Ambulatory Health Care.
Q: How does Orthopedic Surgery Center of Orange County ensure completeness and accuracy is maintained in all medical charts?
Dr. Alan Beyer: In our ASC, we might have a physician that does 600 cases per year, and another physician that does 60 cases per year. Obviously, a hand or sports medicine specialist is going to be doing more cases than a spine specialist. So depending on what specialty any of our physicians are in, a varying number of each physicians charts will be randomly pulled for auditing. The surgery center as a whole decided we're going to audit 10 percent of every physician's medical charts every year. So if one of our specialists does 600 procedures, a higher number of his charts will undergo review than an associate who does 60 procedures. The minimum number across the board is 10 percent of yearly medical charts.
Q: What does the actual auditing process entail?
AB: One of our nurses randomly picks 30 charts each month. We have 17 physicians on staff, so on a rotating basis each of our physicians will do all 30 chart reviews. The only caveat is that month a physician is chosen to review charts, none of his own charts are amongst the 30 that are chosen. There is a formalized template that includes a whole checklist, including information about pre-operative work, adequate history and physical examination, information about the operation itself, any complications, post-operative orders and so on. The template they have to go through has a check for each required entry. Then the reviewer either says it's acceptable or needs to be reviewed by our medical advisory committee for review over any questionable charts.
Q: Which physicians or staff members make up the medical advisory committee, and how is the review process by the committee carried out?
AB: The medical advisory committee is made up of our board of managers, which are four orthopedic surgeons, an anesthesiologist, the director of the surgery center, which is one of our registered nurses, and one member of the hospital administration at Hoag Memorial Presbyterian Hospital, who is our joint-venture partner. The first thing the committee does is discuss the [questionable] chart, and based on the chart and circumstances involved with whatever the deficiency in the chart was, it will decide if the chart can be approved or if it needs to be sent back to surgeon to have his error explain and remedied. If it was a simple deletion, it's simply sent back to be filled in. It is an educational opportunity to inform physicians and the staff of errors that can be prevented or change any procedures or protocols to ensure medical charts are done completely and accurately.
Learn more about Orthopedic Surgery Center of Orange County.
Q: How does Orthopedic Surgery Center of Orange County ensure completeness and accuracy is maintained in all medical charts?
Dr. Alan Beyer: In our ASC, we might have a physician that does 600 cases per year, and another physician that does 60 cases per year. Obviously, a hand or sports medicine specialist is going to be doing more cases than a spine specialist. So depending on what specialty any of our physicians are in, a varying number of each physicians charts will be randomly pulled for auditing. The surgery center as a whole decided we're going to audit 10 percent of every physician's medical charts every year. So if one of our specialists does 600 procedures, a higher number of his charts will undergo review than an associate who does 60 procedures. The minimum number across the board is 10 percent of yearly medical charts.
Q: What does the actual auditing process entail?
AB: One of our nurses randomly picks 30 charts each month. We have 17 physicians on staff, so on a rotating basis each of our physicians will do all 30 chart reviews. The only caveat is that month a physician is chosen to review charts, none of his own charts are amongst the 30 that are chosen. There is a formalized template that includes a whole checklist, including information about pre-operative work, adequate history and physical examination, information about the operation itself, any complications, post-operative orders and so on. The template they have to go through has a check for each required entry. Then the reviewer either says it's acceptable or needs to be reviewed by our medical advisory committee for review over any questionable charts.
Q: Which physicians or staff members make up the medical advisory committee, and how is the review process by the committee carried out?
AB: The medical advisory committee is made up of our board of managers, which are four orthopedic surgeons, an anesthesiologist, the director of the surgery center, which is one of our registered nurses, and one member of the hospital administration at Hoag Memorial Presbyterian Hospital, who is our joint-venture partner. The first thing the committee does is discuss the [questionable] chart, and based on the chart and circumstances involved with whatever the deficiency in the chart was, it will decide if the chart can be approved or if it needs to be sent back to surgeon to have his error explain and remedied. If it was a simple deletion, it's simply sent back to be filled in. It is an educational opportunity to inform physicians and the staff of errors that can be prevented or change any procedures or protocols to ensure medical charts are done completely and accurately.
Learn more about Orthopedic Surgery Center of Orange County.