MSCHE/ACOE Self Study

8.2.4. Patient records allow for efficient review of the patient’s condition and any previous care that has been provided at the program’s clinical facility. Current patient records (and past records of active patients) are stored in an electronic format. The UEC Policy and Procedure Manual M-2 addresses specifically what information should be contained in the medical record. Access to records is restricted to the practitioner or student who sees the patient. An audit trail can be obtained of who viewed a patient record. The confidentiality of patient information is of paramount concern. Students, faculty and staff are reminded periodically about confidentiality of clinical records. Currently, our HIPPA position is vacant and the VP of Clinical Affairs is temporarily filling this role. The UEC also has a part-time compliance officer for issues related to “Business Integrity”. Access to records by accreditation site teams must adhere to HIPAA regulations ( UEC Policy and Procedure Manual H-4 and 5). 8.2.5 The clinic conducts an ongoing, planned quality assessment, improvement and compliance program that evaluates the provision of health, eye and vision service and provides for remediation when deficiencies are identified. Quality Assessment and Improvement The UEC’s Quality Assessment and Improvement Plan can be found in Appendix 5 of the Policy and Procedure Manual (Goal 3.2). It is the University Eye Center’s policy to review charts of patients seen within the UEC’s in-house clinics. The quality and appropriateness of care rendered by faculty to patients are retrospectively reviewed by the Quality Assessment and Improvement Committee (QA). This team meets weekly. Generally, a minimum of 10 records are reviewed for each faculty member per year. From 2000-2009, over 16,500 charts have been reviewed. Records are compared against the protocols published by the University Eye Center. Records are "flagged" whenever an error, omission, or other failure to comply with the Institution's clinical management protocols may adversely affect the outcome of the patient encounter, as follows:  Level Zero: a note to the practitioner. No clarification or correction required, for informational use only.  Level One: minor error(s) or omission(s) in the record without impact on patient care. Requires clarification or correction by the attending doctor.  Level Two: significant error(s) or omission(s) in the record which may affect patient care. Requires clarification or correction by the attending doctor.  Level Three: potentially sight or life threatening error(s) or omissions. Requires immediate attention by the attending doctor.

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