Why is the patient’s medical record considered an integral part of the tracer methodology?
Ans) The tracer methodology uses actual patients to assess care and compliance with relevant standards. Medical records play an important role in this new process.
- Surveyors will randomly select patients--and subsequently, their medical records--at the beginning of the survey.
- The surveyors will visit the units, sites, or departments in the exact sequence, when possible, the patients experienced.
- For example, a patient is admitted through the emergency department (ED) and admitted to the cardiology unit, where he has a cardiac catheterization. He receives x-rays, lab work, and medications; is put on a special diet; and is transferred to the cardiac rehabilitation unit after discharge.
- The surveyor would follow--or trace--the path of the patient and talk to the direct caregivers who provided care and treatment to the patient.
- Surveyors will generally select open records for this review; however, it is possible for a surveyor to request closed records if a patient was a recent readmission.
- Other closed records requests could result from the inability to locate enough patients hospitalized at the time of survey--if surveyors wish to trace patients in restraints, for example, and none are available. Open or closed, quality medical records have never been more important.
Why is the patient’s medical record considered an integral part of the tracer methodology?
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what type of agreement become a permanent part of the medical record?
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