Quality Assurance in Medical Records

Rajakumar.M,
Manager-Medical Records,
Aravind Eye Care System.

The evaluation of medical care is as old as medicine itself. There is evidence of public effort to control the quality and cost of medical care throughout history. With the advent of widespread third-party involvement in the financing and reimbursement of health care, mechanisms which were designed to ensure that the medical care provided to individual patients was medically necessary, were developed.

Medical Audit:
Medical audit is an audit methodology designed to assist hospitals to objectively review and evaluate patient care. It has a specific standard according to which the hospital has to demonstrate a consistent endeavor to deliver patient care that is optimal within available resources and consistent with achievable goals. A major component in the application of this principle is the operation of a quality assurance program

The term quality assurance program which is used today, is a broad term that encompasses several components: 1) utilization review 2) medical care evaluation 3) risk management, and 4) peer review. Whatever the approach to the evaluation of quality patient care, in all of these efforts the major elements in maintaining quality assurance programs are

Gathering of data

Assessment and analysis of data

Acting on the findings

Continuing the monitoring process

Utilization Review
Utilization review is a process by which the use of available health care facilities and services are evaluated. The objectives of utilization review are to

Assure placement appropriate to patient needs

Provide professional accountability for the utilization of health care resources to the patient and the person or organization paying for the care.

Medical care evaluation
Medical Care Evaluation (MCE) focuses on the quality of care provided in an institution. MCE studies are conducted to promote the most efficient and effective use of available health facilities and services, which are consistent with both patient needs and professionally recognized standards of health care. Where appropriate, MCE studies should result in recommendations for changes, which benefit the patient, staff, facility and community.

Evaluation of the patterns of medical care rendered in an institution may be monitored through medical care evaluation studies, which are often referred to as patient care audits. A patient care audit focuses on upgrading patterns of care in an institution rather than identifying individual practices or deficiencies. The primary purpose of the MCE study is to assure that the health care received by patients is of optimal achievable quality.

Medical care evaluation studies or audits are the responsibility of the medical staff. These audits are designed to assess the quality of care through a retrospective examination of certain key elements in specific diagnostic categories. Criteria for evaluation are drafted and approved. Data are abstracted from the medical record according to the criteria outlined.

Patient care audits may be conducted to study either the process (methods) or outcomes (results) of treatment. Process audits examine whether specified procedures thought necessary for patient care are actually performed. Outcome audits assess medical care by looking at the condition of the patient during and after treatment. Results are then compared with hospital, regional, and national standards.

Risk management programs
Hospital risk management programs are developed to control liabilities for human errors and equipment failures. Their goal is to control preventable risks and keep to a minimum the incidents for which the institution can be held liable. It involves all levels of hospital personnel and their data-gathering efforts are concentrated on patient risks from the environment, the use of medical equipment, the services that are rendered, and the safety measures that are taken

Peer review
Medical record professionals, by fulfilling certain educational requirements are competent to practice their profession. By working in the profession, cooperating with other health professionals and organizations and providing services consistent with the needs of their health facility, they are considered to be practicing the art of medical record science. But the learning process continues with the day-to-day activities of work, there are always new areas of interest to explore, new developments in the health care field to contend with, and changes to be made to advance the practice of medical care. All health care professionals, through the process of self-assessment and continuing education, should strive to systematically and individually continue a program of self-improvement.

Medical Record Committee
The committee should be established in each and every hospital to review periodically the quantitative and qualitative services rendered by the medical records. This should include the record format, clinical pertinence, legibility of documentation, completion, overall adequacy, accuracy of coding, indexing of diseases and operation procedures, collection and preparation of statistical information.