Medical Record Review (JCAHO)

Description

The Medical Records Review internal Web site enables UAMS to review representative samples of patients records each month to ensure that providers are documenting according to Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. The UAMS Health Information Management (HIM) department manually enters details from randomly-selected patient charts to create new cases in the system. A review process shows compliance with requirements for recording patient demographics, history and physical (H&P) exams, operative notes, discharge information and more. The HIM staff then reports these record audits to the Medical Record Committee, service line directors and other UAMS leaders.