Medical Records Review and Assessment
A self-assessment tool is provided to licensed members for their use in assessing the quality of their own medical records. Use of this tool may be helpful before your facility undergoes an Accreditation Inspection and/or before you volunteer to submit records for a peer review. The self-assessment can be completed by an individual veterinarian or by the entire veterinary team as a group exercise.
Self-Assessment Tool Components:
The College places a strong emphasis on supporting high quality medical records in its Quality Practice Program. Trained peer reviewers assess medical records as part of the facility Accreditation process, and for practitioners who wish to improve their record keeping by volunteering for peer review.
Assessments of medical records are based on legislative requirements and professional expectations for medical record keeping. To assist veterinarians or veterinary practices with preparing for a peer review, and as a resource to others, the assessment questions are provided:
Peer Review of Medical Records participants gain valuable insights into their record keeping processes. After considering the comments from reviewers, veterinarians have made improvements to their records that result in more efficient use of time for all team members, better communication between staff and with clients, and increased capacity to ensure the continuity of care provided to patients.
Individual veterinarians or veterinary practices may volunteer to participate in a Peer Review of Medical Records. Records submissions from a practice must be submitted by the practice director or be accompanied by the practice director’s permission to participate.
The records package submitted for review normally includes complete copies of medical records for eight recent cases including relevant components. It is recommended that the selected records include two each of the following case types: acute medical, chronic medical, surgical, and wellness or herd-health.
The following information sheet will assist you in understanding the process and preparing your records package for submission:
Once your records package is received by the College, it will be assigned to a trained peer reviewer for assessment. The College's aim is to complete the assessment and report within 6 weeks. You will be provided with a copy of the report when the submitted records are returned to you. All information and correspondence relating to the Peer Review of Medical Records remains confidential and is shared only with Quality Assurance Committee members in aggregate form.
Veterinarians and practice directors interested in participating in Peer Review of Medical Records are asked to contact Megan Callaway, Principal, Quality Practice, at firstname.lastname@example.org to obtain further instructions and forms to assist with the preparation of your records package for review.
An Enhancement of the Accreditation Renewal Process
Of the practices undergoing inspection prior to renewal of their certificate of accreditation, approximately 20% are randomly selected to participate in a Peer Review of Medical Records. Practices selected for peer review will be notified by the Accreditation team. Selected practices will receive a letter and information package including the following information sheet along with other forms to assist in preparing their records package for review: