Clinical Records Run-down Series Part 1

As an overall portion of maintaining surgery center accreditation and certification the center must uphold compliant medical/clinical records.  I will be providing a series of blogs based on the “run-down” of what you need to know to have a performance rate of 100% compliance for your clinical record entry.  Did you know that clinical records technology can help maintain compliance? Check out my side bar to try Practice Fusion EHR for free today.

“The Health Information Technology for Economic and Clinical Health Act (HITECH Act or “The Act”) is part of the American Recovery and Reinvestment Act of 2009 (ARRA). ARRA contains incentives related to health care information technology in general (e.g. creation of a national health care infrastructure) and contains specific incentives designed to accelerate the adoption of electronic health record (EHR) systems among providers.”

Because this legislation anticipates a massive expansion in the exchange of electronic protected health information (ePHI), the HITECH Act also widens the scope of privacy and security protections available under HIPAA; it increases the potential legal liability for non-compliance; and it provides for more enforcement.”

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Now your clinical records must reflect the perioperative care given.  The clinical record has to be legible, done in a timely manner, and documented accurately.  To start this ball rolling please refer back to my post What Postings Are in your Surgery Center Lobby.  I reference this post because the items posted and addressed in the lobby you will need to obtain an acknowledgement signature from your patients denoting that they have a clear understanding of who, what, when and where specifics of the procedure. The facts are you need signed confirmation that the patient knows the ownership of the facility if the physician/surgeon performing the procedure has any ownership in the center.  Even if the surgery center is not physician owned, ownership must be disclosed.  You also need confirmation from the patient that they understand and were provided information regarding rights, responsibilities, notice of privacy practices and whether or not your center will honor advance directives.  FYI– be sure that the patient checks off on your form either “YES” or “NO” to confirm whether they have an Advance  Directive or not(doesn’t matter whether you honor AHCD or not).

There’s the patient demographic information that has to be filled out, make a copy of the insurance card and identification card i.e. driver’s license.  FYI-If you want to make your life easier during the surgery center accreditation survey incorporate an acknowledgement sign off sheet that the patient understands all fees and billing whether the payments are processed via the insurance carrier, billing company, cash or credit.

If you are preparing for reaccreditation for your surgery center keep this in mind:

  1. The surveyor will review at minimum 15 clinical record charts.  Some surveyors will ask to see your surgery log book and narcotic log book to cross reference to and request you pull the names or patient identification number of charts they want to review.

When was the last time your Nurse Manager performed a chart audit?

Did you know that whether your billing is done internally or externally you must perform audits to govern for compliancy?  No matter who performs the billing, the center (Governing Body) is legally responsible for accurate billing of services.

Here’s to your success,


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