Medical Records Review and Assessment
Notice of Changes to Peer Review of Medical Records
The College places a strong emphasis on supporting high quality medical records in its Quality Practice Program. Medical records provide the basis for the continuity of veterinary care. A complete medical record tells the story of the quality of care provided to an animal or group of animals and ensures that care can be resumed seamlessly from one veterinarian to the next, from one visit to the next. To mitigate risks to the public, Peer Review of Medical Records supports veterinarians in meeting the standards for medical record keeping that ensure optimal veterinary care can be continued.
In March 2018, Council formally established Peer Review of Medical Records as a mandatory component of the College’s Quality Assurance Program by moving oversight of the inspection of records for the purpose of PRMR from the Registrar to the Quality Assurance Committee. The authority to inspect the records of a given practice will remain that of the Registrar as per section 50 of Ontario Regulation 1093.
With direction from the Quality Assurance Committee, a redevelopment project was undertaken by the College in 2018 to strengthen learning outcomes of the Peer Review of Medical Records process. The PRMR process will resume on March 1, 2019 and will be evaluated after two years. Changes to the PRMR process include revised selection criteria, measures for determining a successful assessment, and re-evaluation of records for practices that do not achieve a successful result in their assessment. Participation is mandatory under section 50 of Ontario Regulation 1093.
Veterinary practices chosen for a Peer Review of Medical Records are identified through a random selection process. Approximately 5% of practices are randomly selected to participate in a Peer Review of Medical Records per year. All accredited veterinary practices are eligible for random selection, with the following exceptions:
- Practices that have successfully completed a PRMR Assessment within the last five years.
- Practices within their first two years of operation.
- Practices within one year of the renewal of their Certificate of Accreditation
- Practices with current limitations, terms, or conditions on their Certificate of Accreditation related to medical record keeping.
PRMR Assessment Outcomes
The assessment tools used by Peer Reviewers will remain the same. Assessments will have a total score which will classify practices into a ‘successful’ category, ‘partially successful’, or ‘not successful’. These categories correspond to a series of evidence-based cut-off scores. Practices in the ’not successful’ or ’partially successful’ categories would undergo re-evaluation of medical records after corrective actions were completed. If re-evaluation of records of a practice in the ’not successful’ category shows no improvement, this will be brought to the Registrar for review.
Practices deemed ‘not successful’ would be required to take corrective actions as determined by a peer mentor. Practices deemed ’partially successful’ will be advised to take self-directed corrective actions to improve record keeping to prepare for re-evaluation. ’Successful practices’ will receive feedback on any gaps in record-keeping and suggestions for improvement.
Peer Review of Medical Records Process
Trained Peer Reviewers assess medical records of practices that are randomly selected to participate in a Peer Review of Medical Records, and for veterinarians or veterinary practices who wish to improve their record keeping by volunteering for peer review.
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 veterinary care.
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:
The Peer Review of Medical Records Assessment Report is confidential and cannot be shared with College committees. Information gathered from Reports will only be shared in aggregate form. In rare cases, serious concerns identified by the Peer Reviewer may be brought to the Registrar for review. This only happens if public safety is a significant concern and only the area(s) of risk or concerns will be brought forward; the Report will not be shared.
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 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 Guidelines for Participation, and Selection and Submission of Medical Records 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 six weeks. You will be provided with a copy of the report when the submitted records are returned to you.
Veterinarians and practice directors interested in participating in a Peer Review of Medical Records are asked to contact Megan Callaway, Principal, Quality Assurance & Improvement, at firstname.lastname@example.org to obtain further instructions and forms to assist with the preparation of your records package for review.
Veterinary practices chosen for a Peer Review of Medical Records are identified through a random selection process. Participation is mandatory under Section 50 of Regulation 1093. Approximately 48 practices per year are randomly selected to participate in a Peer Review of Medical Records. Selected practices will receive a letter and information package including the following guidelines along with other forms to assist in preparing their records package for review.
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 you participate in a Peer Review of Medical Records or before your facility undergoes an Accreditation Inspection . The self-assessment can be completed by an individual veterinarian or by the entire veterinary team as a group exercise.
Self-Assessment Tool Components: