One of our major tasks in the case review process at KFMC is to try to make accurate judgements regarding the appropriateness or quality of care based solely on the documentation provided in the medical record . Obviously, the delivery of medical care is a complex, multifaceted, interpersonal interaction occurring in real time. But all we have to go by is what's written in the chart . So, as one might easily imagine, a frequent problem we encounter is - inadequate documentation in the record to allow us to make a determination whether there are any quality of care or utilization concerns.
Every case is different.
Sometimes it's a simple matter of obtaining a missing x-ray report, for example. But more often, there's a gray area and we must decide at one point poor documentation becomes a quality of care concern. Our first step will be to try to obtain the missing documentation. This site is a public service of the Kansas Foundation for Medical Care.