Q&A: Clarifying MS.03.01.01 EP 7 (Medical staff monitors quality of H&P examinations)

Q: During the on-site survey, we were cited due to a lack of H&P completions. How can I clarify this?

A: If medical records monitors this on a regular basis as discussed in the previous citation and the information (such as delinquencies) is reported back through the medical staff in some manner, you might be able to overturn this finding.

Also, consider what elements of the record are examined in the medical record peer review process.

Articulate how this process works in your organization and how the medical staff is involved with medical record delinquencies or quality follow-up on this issue.

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