Limited Adverse Occurrence Screening: A Program with Significant Benefits for the Medical Record Department

Abstract

Quality is a major issue in industry. However, the performance of hospitals is predominantly measured by quantity. There is little accurate measurement of, and control over, the quality of patient care provided. Traditional medical quality assurance methods do not meet the basic criteria of an effective control system as defined in management theory. Occurrence screening is a method of medical quality control that overcomes many of these deficiencies. It detects adverse patient occurrences by screening medical records using outcome criteria and selective medical record review. The implementation of an occurrence screening program using a small number of criteria and retrospective review in the Medical Record Department of a 200 bed base hospital is described. Screening has been integrated into daily work practices in an efficient and cost effective manner. Medical record staff have become more aware of the importance of complete documentation and the profile of the department in the hospital has risen. Significant patient care problems have been detected by the screening process.