Nursing Peer Review is Required by the State
Peer reviews, which differ from basic chart reviews, are a structured look at medical records to make sure they are accurate, complete, and follow processes and compliance standards. Peer review legislation has been enacted in each of the 50 states.¹ Sites that do not peer review nursing staff may be out of compliance. A site looking to implement or improve their peer review process should ensure they are partnering with qualified reviewers and appropriately analyzing their processes regularly.
Only RNs can peer review
Before a peer review can be completed, be sure to choose the right person for the job. Peer reviewers may be assigned or self-selected based on eligibility criteria. A peer reviewer should be a Registered Nurse (RN) or above. No licensure below RN should complete peer reviews, as most state licensing boards only allow LPNs and below to work under the direct supervision of an RN or above. This means that while LPNs and Paramedics can do simple chart checks for completion, only RNs can peer review in-depth.
Conduct peer reviews every other month
Although there is no standard for how often peer reviews should take place, jail standards require that they are completed. ²,³ It is recommended to complete a peer review every 2 months to ensure ongoing compliance. Basic chart reviews should be conducted even more frequently. At least weekly nursing staff should perform quick chart checks for completion. Blank spaces or missing items like weight and vitals should be resolved. For more in-depth peer reviews, RNs should look for:
· Accuracy and completeness
· Proper use of terminology and standard documentation practices
· Compliance with processes and regulatory standards
· Appropriateness of interventions and care planning
If a concern or discrepancy is noted, it should be documented and addressed. If a significant concern is identified, the review should be escalated appropriately up the chain of command. Don’t just review the chart and move on. Conduct peer reviews every other month for continuous quality improvement.
Audit review processes annually
Peer review processes should be reviewed by medical leadership at least annually for quality assurance and compliance. During this review, leadership can audit and reference best practices or regulatory changes to update the peer review process as appropriate. For example, each peer review should be conducted with strict adherence to confidentiality processes, such as HIPAA. Document the results of annual audits to keep a record of your facility’s compliance in the peer review process. Keep your peer reviews compliant and audit review processes annually.
For more information, please contact training@sparktraining.us.
1. Lindor, R. et al. (2021). State Variability in Peer Review Protections Heightens Liability Risks. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 5(2), 476-479. https://doi.org/10.1016/j.mayocpiqo.2020.10.011
2. American Correctional Association. (2023). ACA Performance-Based Standards and Expected Practices for Adult Correctional Institutions, 5th Edition, Standard 4 ALDF – 4D – 25.
3. National Commission on Correctional Health Care. (2018). Standards for Health Services in Jails, Standard J-A-06.
Disclaimer
All materials have been prepared for general information purposes only. The information presented should be treated as guidelines, not rules. The information presented is not intended to establish a standard of medical care and is not a substitute for common sense. The information presented is not legal advice, is not to be acted on as such, may not be current, and is subject to change without notice. Each situation should be addressed on a case-by-case basis. When in doubt, send them out!®
