Chart Selection and Review Instructions for Hospitals

Chart Selection and Review Instructions for Hospitals

Purpose

The goal of chart reviews is to determine why readmissions occur in order to test changes and eliminate failures in the discharge process. Reviewing these charts is intended to identify opportunities to improve processes and the quality of care by reducing unnecessary readmissions. The intent is not to place blame on any individuals.

Reviewers and their Frame of Mind

Reviewers may be nurses or medical record personnel who have clinical and/or chart review experience.Selected personnel must understand that reviewing the charts is intended to identify opportunities to improve processes and quality by flagging safety issues, avoiding future unnecessary readmissions, and potentially avoiding future adverse events. The intent is not to place blame on any individuals.

Instructions

Chart Selection

Choose 30 patient charts, starting with the most recent, that have been readmitted within 30 days. Go back as far as you need to in order to get 30 charts. Choose a diagnosis that you want to focus on (heart failure, acute myocardial infarction, pneumonia) for the index admission. You can use“all cause” for the readmission. Do not choose charts where the readmission was planned. Also, only select Fee-for-Services Medicare patients for review.

Chart Review

Using the chart review tool provided by CCME, look through the chart for the items listed or anything else that may have contributed to the patient’s unplanned readmission. Notes can be written at the end of the form. Depending on how your medical records are set up not everything may be captured. Please write the diagnoses in the Diagnosis Section. Do not use ICD9 code.

Once the chart review is complete, please send all forms as PDF files to Linda McNeillat . CCME will then complete the analysis.

This material was prepared by The Carolinas Center for Medical Excellence, the Medicare Quality Improvement Organization for North and South Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-NC-C8-12-18