Chart Review Activity

Quantitative (record completeness documents are present, forms authenticated)

vs

Qualitative (quality and adequacy; timeliness of documentation, legibility, thoroughness)

1. Dr. John Jones dictated an H&P on Mrs. Karen Winterswhile she was admitted to the hospital. Winters was discharged last week and Dr. Jones has yet to sign off on the H&P.

What type of review would this problem fall under?

i. Quantitative

ii. Qualitative

Why? ________________________________________________________________________________________________________________________________________________

2. A physician documents by exception.

What type of review would this problem fall under?

i. Quantitative

ii. Qualitative

Why?

________________________________________________________________________________________________________________________________________________

3. Dr. Harris Rinehart gave a VO/TO to Taylor Farris, RN onOctober 12th, 2019. As of today Dr. Rinehart has not signed off on the VO which he gave to Taylor.

What type of review would this problem fall under?

i. Quantitative

ii. Qualitative

Why?

________________________________________________________________________________________________________________________________________________

4. Mrs. Kitty Wells was admitted today, November 14, 2019, and upon review of her chart it was noted that an H&P was found dated from October 18, 2019. Mrs. Wells has not had any significant changes to her medical history or condition since her last appointment with her physician.

Is this an acceptable timeframe for her H&P? _____________________________

5. Mr. Jim Caldwell presented for a colon resection surgery this morning at 8:00 am.

What specific document must have been on the chart prior to surgery? ____________________________________________________________

What specific document must be dictated ASAP and no later than 24 hours of surgery? ______________________________________________________________

6. You are reviewing the chart for completeness of documentation for Wendy Jones surgery on October 25th. You were able to locate the following items:

H&P

Pre-Op anesthesia evaluation

Intra-Op documents

Operative report

Discharge summary

What type of review would this problem fall under?

i. Quantitative

ii. Qualitative

Why?

________________________________________________________________________________________________________________________________________________

Incomplete (missing items) vs Delinquent (fallen beyond the record time frame)

1. Dr. John Jones dictated an H&P on Mrs. Karen Winters while she was admitted to the hospital. Winters was discharged last week on November 7th. As of this morning Dr. Jones has yet to sign off on the H&P.

a. Incomplete

b. Delinquent

Why? ________________________________________________________________________________________________________________________________________________

2. Mrs. Betty White was discharged on October 1st, 2019. As of this morning her discharge summary has not been signed off on by the physician.

a. Incomplete

b. Delinquent

Why?

________________________________________________________________________________________________________________________________________________

3. Sal Smith passed away on October 15th, 2019. As of this morning his final autopsy report has not been issued.

a. Incomplete

b. Delinquent

Why?

________________________________________________________________________________________________________________________________________________

4. Dr. Harris Rinehart gave a VO/TO to Taylor Farris, RN on November 11th, 2019. As of today Dr. Rinehart has not signed off on the VO which he gave to Taylor. (Our facility practices per CMS CoP)

a. Incomplete

b. Delinquent

Why?

________________________________________________________________________________________________________________________________________________