Policies,Administrative,UW Health Administrative,Health Information Management

Medical Record Monitoring for Documentation (6.22)

Medical Record Monitoring for Documentation (6.22) - Policies, Administrative, UW Health Administrative, Health Information Management


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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).

Policy Title: Medical Record Monitoring for Documentation
Policy Number: 6.22
Effective Date: July 3, 2017
Chapter: Health Information Management
Version: Revision


To ensure documentation standards set forth in the Administrative Policies and Procedures are observed
by the medical and patient care staff. To assist the medical staff, GME staff and other clinical staff
members with teaching appropriate documentation skills. To comply with The Joint Commission (TJC)
and Centers for Medicare and Medicaid Services (CMS) standards on timeliness, completeness, and
accuracy of medical records.


Ongoing review of medical record documentation is performed on a regular basis by the Health
Information Management Department (HIM), Nursing Services, Ambulatory Clinics and Clinical
Departments. The results of these reviews are reported regularly to their respective oversight committees
with suggestions for education or improvement, as needed.


Clinician Author: A clinical staff member who has the authority and responsibility for creating and/or
authenticating patient health record entries. Examples include: Physicians, Advance Practice Nurses,
Certified Nurse Midwives, Physician Assistants, Psychologists, Pharmacists, Speech Language
Pathologists, Audiologists, Licensed Clinical Social Workers, Registered Nurses and any other health
care professional licensed, credentialed, and/or approved by UW Health to document in the patient health
record. Clinician Author also includes residents and students in approved health occupation programs
under the supervision of a clinical staff member.


A. Chart Completion Review
The HIM department reviews all inpatient, observation and ambulatory surgery records for
completion and authentication of the discharge summary, face sheet, operative report and history
and physical. The appropriate clinician author is notified and asked to complete documentation
prior to filing of the record as a closed medical record. The chart completion rate is reviewed by

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the Medical Record Committee at its monthly meeting (see Hospital Administrative Policy
6.17-Centralized Monitoring of Delinquent Medical Records).

B. Documentation Review
The Medical Record Committee or hospital leadership reviews results of the following
documentation audits, identifies areas requiring more or less intensive review and determines
thresholds and scoring guidelines to be utilized in assessing compliance with documentation

The Medical Record Committee forwards recommended actions regarding medical staff
documentation to the Medical Board based on results of the review.
1. Inpatient Records
A sample of each clinical service’s current inpatient records are reviewed on a weekly basis
for compliance with documentation standards. Results of the review are reported in
aggregate to the Medical Record Committee and to each Clinical Department Chair,
Section Head, or designated department administrator at the individual clinician author
2. Inpatient Nursing Service
Nursing Services conducts ongoing documentation review. Results of the review are
reported in the monthly nursing report card and reviewed regularly at the Nursing Quality
Council, with recommendations of process improvement work if needed.
3. Ambulatory Review
A sample of each ambulatory location’s current patient records are reviewed on a monthly
basis for compliance with documentation standards. Results of the review are reported each
month to ambulatory clinic leadership and reported regularly in aggregate to the
appropriate regulatory committee with recommendations for process improvement if


Sr. Management Sponsor: SVP, Chief Information Officer
Author: Director, Health Information Management
Reviewer: Medical Records Committee.

Approval Committee(s): UW Health Administrative Policy & Procedure Committee


Elizabeth Bolt
UW Health Chief Administrative Officer