Most Common Deficiencies For AAAHC Chapter 6 “Clinical Records and Health Information”
The most common deficiencies our surveyors see for Chapter 6 “Clinical Records and Health Information” of the AAAHC Accreditation Handbook for Ambulatory Health Care:
All allergies must have the reaction listed. If the patient does not know (or can’t remember) the reaction to their stated allergy, then writing “Unknown” is acceptable.
Allergies must be consistently located in a prominent section of the patient chart and must document the specific reaction. Be able to state this primary location for allergy documentation.
Allergies must be updated and verified at every visit.
For paper charts of patients with three or more visits, the chart must have a diagnostic summary of past procedures. This should be in the front of the chart. For centers with an EMR, the system usually creates this automatically.
Medication reconciliation – this must be in the chart for every visit. Often, this is missing.
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*Sources:
“AAAHC Quality Roadmap 2019” report: applies to Ambulatory Surgery Centers, Office-Based Surgery practices, and Primary Care settings.
HealthCon Consultant survey experience