Q&A: The mechanics of a clarification

Q: Do you have any advice on how to format evidence for a clarification or choosing a sampling method to submit to The Joint Commission?

A: Note the following excerpted example that uses an audit submitted for a clarification by a client. It is very clear how the medical records were sampled during the audit process and it leaves no doubt as to potential bias or skewing of the data or the validity of the outcome. Of course, the data would also be submitted to support the claim. This submission leaves a perception of confidence in the organization’s ability to correctly assess and support its claim of compliance.

Sampling method: The hospital discharged more than 2,000 patients in the 30 days preceding the survey; a sample of 70 medical records was anticipated. A list of the 2,443 patients admitted on or after January 6, 2011 (30 days prior to the beginning of the survey), and discharged on or before February 4, 2011 (the day before the survey), was prepared. Every 80th patient on the list was selected for review. Nine of these records were arbitrarily omitted from the sample prior to the review, leaving 71 records in the final sample.

Read the rest of this answer on the AHAP blog.

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