Best Practices for Preparing Clinical Patient Samples

Health centers are required to provide a sample of patient medical records during an Operational Site Visit (OSV) for the following clinical chapters:

• Chapter 4 – Required and Additional Health Services
• Chapter 7 – Coverage for Medical Emergencies During and After Hours 
• Chapter 8 – Continuity of Care and Hospital Admitting 
• Chapter 10 – Quality Assurance/Improvement

Adequate knowledge of the required sample composition, a thorough understanding of the intent of the requirement and proper preparation will help ensure a smooth OSV process.

Below are some best practices to follow when preparing clinical sample patient records for an OSV:

• Before beginning to gather and organize sample patient records, it is important for staff to understand the specific compliance areas under review. 
• The health center is in the driver’s seat when it comes to sample patient records. It is at the discretion of the health center to decide which samples will be provided and whether patient samples will be provided via live navigation or via screenshots.  
• Ensure the sample patient records chosen “close the loop.” The intent of the requirement for most clinical chapters is to demonstrate continuity of care through documentation of the service in the medical record and appropriate patient follow-up. 
• If uploading samples, redact Personally Identifiable Information (PII), but ensure a unique identifier is left to allow the reviewer to “connect the dots.”  Typically, the Medical Record Number (MRN) is the easiest way to manage the redaction process.  
• Designate staff who are proficient with the health center’s Electronic Health Record (EHR) to present the samples selected to the clinical reviewer.  Additionally, ensure the appropriate staff are available to handle any questions related to clinical care and patient records.  
• OSV reviewers may ask questions or request explanations for certain elements in the sample of patient records provided. Be prepared to explain the continuity of care process and how the health center ensures compliance with all regulations.

Preparing patient sample records for an OSV is a meticulous process that requires planning and attention to detail. One of the most important things a health center can do is practice how sample patient records will be presented. This will help streamline the process and demonstrate the health center’s commitment to the delivery of quality patient care.

Resources for patient samples can be found in the Health Resources and Services Administration (HRSA) Health Center Program Site Visit Protocol:  Sampling Review Resource Guide