About the Peer Review of Medical Records
The Peer Review of Medical Records (PRMR) is a mandatory component of the College’s Quality Assurance Program. In 2018, the College Council moved oversight of the peer review of medical records from the Registrar to the Quality Assurance Committee. With direction from the Quality Assurance Committee, the College redeveloped the PRMR in 2018 to strengthen learning outcomes. 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. Participation is mandatory.
Selection for a PRMR
Veterinary practices chosen for a PRMR are identified through a random selection process. Approximately 5% of practices are randomly selected to participate each 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 on a case-by-case basis. A facility that had a PRMR Assessment before 2019 is not exempt from random selection.
PRMR 2022 Aggregate Report
Through PRMR, trained Peer Reviewers assess medical records of randomly selected practices and for those who wish to improve their record-keeping by volunteering for a peer review. Practices participating in PRMR gain insights into their record-keeping practices. The PRMR helps to identify areas for improvement and also confirms areas of strength.
The 2022 aggregate report is an informative read to assist with record-keeping. The report shares data from the first full year of the new PRMR process and highlights opportunities for all veterinarians to enhance their record-keeping practices. The report incorporates the results from a participant survey and the scoring results from those practices who have completed the PRMR.
PRMR Summary of Findings
Assessment Outcomes
The assessment tools used by Peer Reviewers 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 that are ‘not successful’ or ‘partially successful’ will undergo re-evaluation after corrective actions are completed. If the re-evaluation 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.
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:
Assessment Questions – Companion Animal
Assessment Questions – Food Producing Animal, Equine, and Poultry
Mandatory Participation
Approximately 84 practices per year are randomly selected for mandatory participation in a PRMR. Selected practices will receive a letter of notification about their selection and will have 30 days to submit their records package.
Information Package - Mandatory Participation
The records package submission 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. The College's aim is to complete the assessment and report within three months 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 for 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.
Voluntary Participation
Individual veterinarians or practices may volunteer to participate in a PRMR. Records submissions must be submitted by the facility director or be accompanied by the director’s permission to participate.
If you are volunteering as a practice and your practice is deemed successful, your practice will be exempt from random selection for five years. 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.
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 PRMR or before your facility undergoes an inspection. The self-assessment can be completed by an individual veterinarian or by the veterinary team.
Self-Assessment Information Sheet
Self-Assessment Form - Companion Animal
Self-Assessment Form - Food Producing Animal, Equine and Poultry