(7) Coordinates with the risk manager and immediately provides him with all data
received in QA activities with known or suspected potential for claims against the MTF.
(8) Acts as a spokesperson for and promotes active participation in the MTF QAP.
(9) Teaches QA methods to all elements of the MTF or coordinates educational
programs with departments and services.
Ensures that the overall MTF QA plan is reappraised at least annually and
recommends appropriate program modification.
3-14. THE ROLE OF THE PATIENT ADMINISTRATION DIVISION
a. The patient administration division (PAD) will conduct administrative record
reviews, give administrative support to the MTF-wide Quality Assurance Program as
prescribed by the local written quality assurance plan, and assist MTF committees and
departments and/or services in patient-care assessment studies as appropriate and in
accordance with AR 40-66.
(1) Inpatient treatment record (ITR) review. When a patient's record is
processed after discharge, the PAD will review the ITR for completeness and assurethat
errors and deficiencies are corrected. Trends in errors or deficiencies or large numbers of
errors or deficiencies should be referred to the Quality Assurance Committee with the
necessary supporting records.
(2) Administrative support for patient care assessment studies. The PAD will
be responsible for retrieving medical records and compiling data for patient care
assessment studies, and referring inpatient treatment records, outpatient treatment
records, and health records to the appropriate committee for documentation review. The
PAD will also furnish any material (i.e., statistical presentation of trends and comparisons)
requested by the Quality Assurance Committee.
b. Medical record personnel will implement an internal QAP that will focus on the
identification, resolution, and followup of existing or potential problems. The overall goal
should be quality records and quality service. This program will be written, and
documentation will support an ongoing assessment of these major functional areas:
(1) Administration or management.
(2) Record review and analysis.
(3) Retrieving, filing, and controlling records.
(4) Correspondence and release of medical information.