CENTER FOR EYE CARE

QUALITY ASSURANCE AND IMPROVEMENT PLAN

 

General medical record standards

LEVEL I: Medical record audit by staff

LEVEL II: Medical record audit by quality assurance faculty

Selected faculty have been designated who have the responsibility on a weekly basis to review randomly selected patient medical records for quality audit. The results of these reviews are forwarded by an automated email system to the student and faculty of record. The results of the audit may suggest no further action is necessary or that some action should be taken. Persistent positive audit can lead to a loss of clinical privileges. The areas of medical record audit are as follows:

• proper documentation and completeness of history
• objective findings written in quantitative terms when appropriate
• impressions based on documented subjective and objective findings
• impressions and plan address subjective and objective findings
• important inconsistencies between subjective and objective findings resolved
• plan includes specific management strategies and treatment prognosis
• informed patient consent or refusal for treatment documented
• justification for the goals and/or management plans stated
• the need for further testing, referral, treatment and/or community services that would be helpful discussed with the patient and documented

LEVEL III: Medical record audit by Center administation

The Assistant Dean for Clinical Programs and the Business and Fiscal Oerations Specialist have been designated to review every record Medicare patients. This is a complaince review to ensure proper ICD-9-CM coding, CPT coding, utilization of services, proper medical record documentation justifying services rendered and verification of superbill and medical record signatures. The results of these reviews are forwarded to the billing staff for electronic billing if the results of the audit are within the acceptable standard. If not, faculty members are contacted to make nedcessary alterations for billing.

LEVEL IV: Medical record audit of additional indicators

Beginning in the fall of 2008, selected faculty and staff will be designated who have the responsibility to review other indicators of quality patient care. The results of these reviews will be published and directed to the apporporiate faculty/students. The results of the audit may suggest no further action is necessary or that some specific action should be taken. Randomly selected patient records will be audited for the following:

• return for evaluation for same or related problem or missed diagnosis
• eye injury or trauma as a result of evaluation
• failure to respond to standard therapy
• adverse or allergic reaction to medication(s)
• consent for additional procedures and medical records releases
• patient leaving before completion of services
• patients that no-show
• patients that fail to keep appointments and follow-up
• documentation of patient instructions
• patient compliance with treatment regimens