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 are central to safe quality veterinary medicine and provide the basis for continuity of care. A complete medical record tells the story of the quality of care provided to an animal or group of animals. 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 peer review 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 (PRMR) process. The PRMR process will resume in March 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.
Updates to the PRMR Assessment Form
In August 2018 the Quality Assurance Committee approved an Annual Cycle for Peer Review of Medical Records. The cycle includes an annual review to evaluate the PRMR process and identify trends in PRMR assessments of practices. Along with this review, staff identify a strategic risk issue (e.g. requirements for written prescriptions) to be included in PRMR Assessments for one year.
The College is launching an updated assessment form for practices undergoing PRMR starting in January 2022.
Selection Criteria
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 within their first two years of operation.
- Practices within one year after the renewal of their Certificate of Accreditation
- Practices with current limitations, terms, or conditions on their Certificate of Accreditation related to medical record keeping.
- A practice that receives a Total Score on the new PRMR Assessment Report to indicate they are successful in meeting requirements will be exempt from random selection for a 5-year period.
Where a practice is selected and has multiple facilities associated with it, and one or some of those facilities are within one year after the renewal of their Certificate of Accreditation, these will be assessed for eligibility on a case by case basis.
A facility that had a PRMR Assessment before 2019 is not exempt from random selection.
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 will undergo re-evaluation of medical records after corrective actions are 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.
Corrective Actions
Practices deemed ‘not successful’ will be required to take corrective actions to improve record keeping and will undergo re-evaluation of their medical records. 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:
Mandatory Participation
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 84 practices per year are randomly selected to participate in a Peer Review of Medical Records. Selected practices will receive a letter of notification about their selection and will have 30 days to submit their records package. The following Information Package and forms will assist selected practices in preparing their records package for review:
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.
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 three weeks from receipt of your records package. The report will be sent to you. It will include a total score which will indicate whether the practice was successful or not in the assessment. If the practice is not successful, directions will be provided to the practice about the next steps, including corrective actions and re-evaluation of records. A practice that is successful in the assessment will be exempted from random selection for a 5-year period.
For more information, click on the link above to review the Information Package – Mandatory Participation.
Voluntary Participation
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 following Information Package and forms will assist you in understanding the process and preparing your records package for submission:
The assignment and assessment of your records package will follow the same process as described in the section above for mandatory participation.
If you are volunteering as a practice and your practice is deemed successful in your Peer Review of Medical Records Assessment, your practice will be exempt from the pool for random selection for a 5-year period. If you are volunteering as an individual veterinarian and working in a multi-veterinarian practice, and your assessment is deemed successful, it will not affect the eligibility of the practice for random selection.
Veterinarians and practice directors interested in participating in a Peer Review of Medical Records are asked to contact the Quality Practice Team at qualityassurance@cvo.org to obtain further instructions.
Self-Assessment
A self-assessment tool is provided to veterinarians 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:
Report on Peer Review of Medical Records - October 2019
The College is preparing a quarterly report on the PRMR process. The report incorporates the results from a participant survey and the scoring results from those practices who have completed the PRMR. Click here to review the October 2019 report on the PRMR.