Having your funders come on-site to review your agency can be a very stressful process. As much as compliance officers attempt to maintain consistency between entities and reviewers, it still can boil down to a matter of interpretation, with findings often based on opinions more than data. Here are some secrets auditors won’t tell you, to help ease the stress.
They’re auditors, not practitioners
Rarely are the people reviewing clinical charts actually clinicians. If they do have clinical credentialing, it has probably been a while since they were in practice. This means they have not had to meet compliance standards in their own documentation in quite a long time.
The reason this is important for you is that sometimes they need reminding that the spirit of a site visit is to ensure quality clinical care rather than just making sure a box is checked. Be sure to discuss with the reviewers the clinical situations of a particular client. Your electronic health record can be particularly helpful in this regard, as it highlights both the technical compliance and the quality clinical outcomes of a particular chart.
Write CliffsNotes, not novels
The people reviewing clinical charts do not read every progress note. Of the notes they do read, they rarely read the entire progress note. The reviewers simply do not have time. They want to get what they need and move on to the next note. So the more you can “spoon feed” them the information, the better you will fare.
Also, if/when they say something was missing from a chart, do not assume it is in fact true. Go back and check yourself to be sure. Utilize your electronic health records to assist the reviewers in locating all the necessary items in a chart or specifically a note.
Offer to lend a helping hand
There is no requirement that you leave the reviewers alone with the clinical records–or any records for that matter, including personnel files and policies. These are the property and responsibility of your agency and you have the right to “keep them in sight” at all times.
Some of the best results can come from your team being present with the records and available to answer questions and assisting the reviewers in navigating the charts. This is especially true with electronic health records: auditors are reviewing your content, not your technology, and they’ve certainly seen countless different variations of software and storage systems. Even the most intuitive EHR may be brand new to them, so offer a helping hand to reduce any unnecessary friction in their process.
Take a representative sample – less is not more!
The charts that are selected by the auditors for review can be negotiated. The “random” name selections are rarely random or representative of the agency. The charts should be representative of your clinicians and consumer population.
For example, if the reviewers select 15 charts and your agency has more than 20 clinicians – it is not a representative sample and every chart carries disproportionate weight. It is better to have the reviewers look at more charts rather than less.
When you receive the names of the clients to be reviewed, go through it and see if it is a representative sample of your agency. If it is not, ask for a few charts to be replaced by explaining why it does not adequately show the full scope of your agency. Using the data in an EHR can help make sure the sample selected is a fair and representative sample.
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