10 Things: Indicators A Program Is Lacking a Quality Assurance Process

Unless you’re brand new to the site, you already know I am a big proponent of quality assurance (QA) and peer review. As a part of my job I review a lot of medical records (nurse- and physician-generated), and there are some things in said records that scream “my program has no QA process”. Since every time I come across one of these issues it takes 4 or 5 days off of my life, in the interest of self-preservation I give you my newest 10 Things:

Indicators A Program Is Lacking a Quality Assurance Process

  1. The patient’s name is spelled 3 or 4 different ways throughout the medical record.
  2. Statements begin, but don’t end–as if the clinician got distracted and then moved on to something else before the thought was completed.
  3. The clinician took 15 photos, but only 8 are recorded.
  4. The body map has N/A (not applicable) next to it, but there are photos of injury.
  5. The medical record is a vast sea of blank spaces.
  6. Colposcope images are numbered on a photo legend, but there isn’t actually something recorded next to every number. (This is, I suppose, a more visually jarring version of #5.)
  7. The record isn’t signed by the treating clinician–anywhere.
  8. Information isn’t recorded in the right spot–for instance in the area of the chart marked history of the assault, there is a description of the assailant (although I don’t think there’s a good spot anywhere in the medical record for that information).
  9. Date of care actually precedes date of assault throughout the record.
  10. The chart is replete with incorrect word choices, misspellings and syntax errors (random quotation marks and misused apostrophes seem to be the biggest culprit).

I absolutely understand that mistakes are made; I’ve made plenty. But I worked with a group that had a rigorous QA process, and that made all the difference. I don’t know any other aspect of healthcare that doesn’t include some type of QA. And the medical record is often where other clinicians, law enforcement and attorneys form their initial impressions of the clinician’s professionalism and ability. If your own program doesn’t have a QA process, I implore you to consider implementing one. For some resources on how to make that happen, check out:

From SAFEta Source:

  1. Chart Audit Tool
  2. Peer Chart and Photodocumentation Form
  3. Peer Review Form
  4. Evidence Kit Evaluation Form

IAFN Webinar on Peer Review (Sue Rotolo and Lisa Gorham) [Handouts from the webinar]

And for the Program Coordinators out there who are concerned about overseeing QA because they’re lousy spellers or are intimidated by semicolons, I have one word for you: delegate.

3 replies on “10 Things: Indicators A Program Is Lacking a Quality Assurance Process”

Sure–I once reviewed a chart for a case and the clinician had written a detailed description of the assailant in the part of the record asking for assault description. That meant that nowhere in the chart was there a description of the assault. It also meant that there was a detailed assailant description, which I personally don’t believe has any place in the medical-forensic record.

Let me know if that doesn’t clarify things.

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