Readily Retrievable Documents

One of the easiest deficiencies a regulatory or accrediting organization can render against an organization is a finding that the organization was not able to provide expected documents.  Staff can be fluent in the specific process that is being explored and do a great job describing the processes to the inspector or surveyor, but when they ask for the organization’s log or other required documents, the organization is not able to produce the document in a timely fashion.   The inspector/surveyor does not need to know anything more than the document is missing, because as the old adage goes…. “If you did not document it- You did not do it”.

Organizations that are most successful in avoiding these types of deficiencies typically have a well-defined process and expectation within each department for managing these documents and we find that the process includes a dedicated location or repository for these documents such as a file drawer or cabinet or binder and that these locations are clearly labeled in an easily identifiable manner.  Unit or department staff are oriented to the location and to both the importance of ensuring the documents are completed as required and when required along with the importance of archiving these documents in an organized manner.   We exist in a world where first impressions are often lasting impressions and when our documents are presented in a well-organized manner, that can speak volumes to the surveyor in terms of the importance of details, accuracy, and accountability to the organization.   There is also great value in including with the log or document any anecdotal notations such as a notation by a supervisor acknowledging the presence of missing documentation. A simple notation of “Noted & Coached” allows the surveyor to see your accountability process in action.

Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting ServicesWith over 29 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.

Please contact Courtemanche and Associates for questions at  704-573-4535 or

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