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August 6, 2021

I am wondering if you have any standard number for the amount of elements in a chart for calculating IRR scores or any formula when calculating scores. Any information or suggestions would help.

You are required to have a plan for IRR, but PTSF does not have any specific required process or number of records for IRR. It can include full record reabstraction or focused review. Reabstraction can be done by one or all registrars. Some ideas include:

•          Full reabstraction of record by one registrar

•          Full reabstraction of a record by all registrars (allows comparison)

•          Focused reabstraction on identified areas (procedures, times, etc.)

•          A registrar leader/supervisor reabstract from each registrar (allows a consistent ‘grading’).

If using a focused approach, full abstraction recommended at least periodically; especially following:

•          Changes/upgrades to your hospital EMR

•          Changes to PTOS data dictionary or the Collector software

•          Staff turnover

The orange book (ACS) recommends review of 5-10 % of records as an approach. You can choose to do less than 5%, but you’ll want to be able to show your detailed process on survey day so they can see your IRR efforts are sufficient.

Educational visits by PTSF staff require an accuracy rate greater than or equal to 96%. We review every PTOS data element, and each is counted as 1 point. For 2021, each record has 412 possible points/data elements that are reviewed.

Lastly, we recommend you focus on PTOS patients when performing IRR. NonPTOS collection is for internal review and may include a very limited data set abstracted. If your center fully abstracts nonPTOS patients, you may want to include them in your IRR process to ensure your internal reporting is consistent and meaningful, but we recommend you focus on PTOS records.

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