A Management System to Maximize Compliance With Standards for Medical Records

A management system designed to maximize staff's compliance with standards for medical records in the periods between external audits was developed for an outpatient network of a large state hospital. The system was based on analysis of the processes and circumstances that enhance compliance with records standards, such as specifying a clear, concrete goal for each chart and having a time-limited review process, and the major inhibitors, such as too-frequent and random audits and lack of internal or external rewards. Data collected on application of the system to 976 charts in the outpatient network showed the system to be effective; between the initial review and the rereview in the third month, the percent of records achieving more than 80 percent compliance with standards rose from 57 percent to 86 percent.