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Standards Concerning Medical Record Documentation – Part 1

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To round-up and complete the subject on the necessary and relevant documentation in a medical record as can be found in the 4th Edition of Joint Commission International (JCI) Accreditation Standards For Hospitals, in this post of two posts, I shall take bring you the final count down of all such necessary and relevant documentation in a medical record.

Health Information Management (HIM) / Medical Records (MR) practitioners please take note (from my knowledge about JCI quality standards) that there are 28 standards with 37 requirements for what information must be recorded in the medical record by the hospital’s various health care providers. Here I mean that there are 37 types of entries that must  be recorded (which includes entries related to the 28 standards) in a medical record.

In the post Medical information that require documentation in medical records (this link will redirect you to a new tab of your current browser window), I had presented all the necessary requirements about of medical information that require documentation in a medical record which explicitly stated what is to be documented in a medical record and also standards which implicitly indicated  medical information that require documentation in a medical record. I had a count of seven (7) standards which explicitly state what is to be documented in a medical record with a total of ten (10) requirements which includes explicit and implicit instances that require documentation in a medical record.

For surgical information that require documentation in a medical record, I had made a count of twelve (12) standards* – or also as one can say “requirements”, which explicitly state what is to be documented in a medical record. There are no standards that indicate implicitly any necessity for surgical information to be documented in a medical record. This bit of information I carried in the post Surgical information that require documentation in medical records (this link will redirect you to a new tab of your current browser window).

Thus from the above, I have a total count of twenty-two (22) standards that make up medical and surgical documentaion in a medical record.

Now, from subsequent posts I had written about other standards that make up for what information that must be recorded in the medical record by the hospital’s various health care providers, I have a count of nine (9) such posts. Here are the relevant links to the posts :

PFE.2 : Medical records should contain the patient’s educational needs assessment documentation

PFE.2.1 : The assessment findings from patient’s and family’s ability to learn and willingness to learn are documented in the patient’s record

ACC.4.4 : 5 transfer process entries that must be entered in a medical record

PFR.6.2 When others can grant consent

PFR.6.3 : General consent is not informed consent

PFR.8 : Informed consent in clinical research, clinical investigation, and clinical trials

ASC.5.1 : Risks, benefits, and alternatives of anaesthesia

MCI.19.3 : JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record – (i) the author can be identified for each patient clinical record entry, (ii) the date of each patient clinical record entry can be identified, and (iii) when required by the hospital, the time of an entry can be identified.

MCI.19.1.1 : JCI MCI19.1 & MCI19.1.1 – Patient Clinical Record – the clinical records of emergency patients include (i) arrival time, (ii) conclusions at the termination of treatment, (iii) the patient’s condition at discharge, and (iv) any follow-up care instructions.

In the coming weeks, I shall be posing on six (6) more standards that require for what remaining information that must be recorded in the medical record by the hospital’s various health care providers.

Once again, I must reiterate that I believe a HIM / MR practitioner working in a hospital must be aware and knowledgeable that the quality of his or her medical records, in his or her custody and care is determined by their contents. The medical records must contain all of the medical information as I spoken of above, recorded in them. This condition is regardless of the type of hospital they work at, irrespective if his or her hospital had acquired JCI accreditation status or one that is seeking JCI accreditation status or it is one that is not seeking JCI accreditation status at all.

*I have updated the post "Surgical information that require documentation in medical records" due to a technical error

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

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Informed consent in clinical research, clinical investigation, and clinical trials

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Secondary purposes of the patient medical record do not relate directly to patient care and includes providing data for use in clinical research, epidemiology studies, education, public policy making, facilities planning, and health care statistics.

Some examples of  patient medical record that do not relate directly to patient care but providing data for use in clinical research include the following:

  1. Alzheimer Registry to collect data to evaluate prevalence of Alzheimer’s disease and related disorders by providing non-identifying information and data for policy planning purposes and to support research
  2. Birth Defects Registry which maintains national surveillance for collecting information on birth defect incidence, to monitor annual trends in birth defect occurrence and mortality, to conduct research studies to identify genetic and environmental risk factors for birth defects, and  promote educational activities for the prevention of birth defects
  3. Cardiac Registry that captures cardiac surgery information as a research tool for assessing cardiac patient outcomes and pinpointing how patient care can improve
  4. Cancer Registry for the management of cancer data collection, recording data elements for each entry that become part of a national registry which is used for education, prevention, quality improvement, and research activities
  5. Trauma Registry of all trauma admissions, deaths in the emergency department due to trauma, recording data elements for each entry that become part of a national registry which is used for education, prevention, quality improvement, and research activities

In this post I shall focus on informed consent that must be obtained when a patient decides to participate in clinical research, clinical investigations, or clinical trials, and skip the discussion on privacy issues and requirements when health care providers routinely allow medical professionals engaged in clinical or epidemiological research to access patient records, abstract individually identifiable information (e.g., date of birth, birthplace, and so on), and exchange that information with other researchers.

Image credit :http://www.cancer.gov/

Informed consent is an ongoing process during which information is presented to an individual patient and families to enable them to voluntarily decide whether or not to participate in or continue participation in clinical research, clinical investigations, or clinical trials. The information provided at the time the decision to participate was made serves as the basis for the informed consent. Informed consent for research involves presenting the research information orally and  obtaining written consent on an approved consent form prior to entering a subject into a study and documenting the consent process in the subjects’ medical record or research file.

Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware that medical records of patients in an ongoing process when such patients participate in clinical research, clinical investigations, or clinical trials will contain the following:

  1. the informed consent form must be dated
  2. the identity of the individual providing the information to the patient and family and obtaining the consent must noted in the patient’s medical record
  3. consent is documented in the patient’s medical record by signature or record of verbal consent

If you are wondering why the patient’s family is involed in obtaining the consent, then the reader should be aware that a family member or person involved in the care of the patient as the participant  are usually encouraged to participate in the consenting process because (i) of the potential subject’s physical and mental state at the time of obtaining the consent, and (ii) to allow time for the patient to consider whether to participate and to discuss the research with his/her family over a period of time (which may include days or weeks). This is especially when particularly complex issues about the research are discussed, an investigator might consider testing the subject’s understanding of the information by asking questions about the presentation and when a family member or person involved in the care of the participant should be encouraged to participate in the consenting process.

At this jucture, I like to advice HIM / MR practitioners who wish to know more about the process of obtaining  informed consent from potential research subjects to explore the ‘Informed Consent  and Authorization Toolkit for Minimal Risk Research’ developed by the Agency for Healthcare Research and Quality (AHRQ). Although this toolkit is applicable in the United States and subject to the Health Insurance Portability and Accountability Act (HIPAA) requirements, it is a good read for understanding  the process to facilitate the process of obtaining informed consent and authorisation from potential research subjects if any such HIM / MR practitioner(s) is/are working at a hospital where clinical research, clinical investigations, or clinical trials is a common activity.

HIM / MR practitioners must also be aware that the Joint Commission International (JCI) Standard PFR.8 which states that “Informed consent is obtained before a patient participates in clinical research, clinical investigation, and clinical trials” and its four (4) Measurable Elements (ME) which must be met fully at hospitals that are JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

HIM / MR practitioners must also check on the process of obtaining signed informed consent when patients voluntarily decide whether or not to participate in or continue participation in a research study which must comply with the requirements of any existing hospital guidelines or hospital policy.  HIM / MR practitioners can be proactive to suggest or initiate proper documentation in medical records for patients who participate in in a research study at the hospital they work at.

Lastly, HIM / MR practitioners do take note that the JCI Standard PFR.8  is checked for compliance in the Medical Record Review Tool form used in the Medical Record Review process if your hospital is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

References:
The Agency for Healthcare Research and Quality (AHRQ), Informed Consent and Authorization Toolkit for Minimal Risk Research,  viewed 20 October 2012,< http://www.ahrq.gov/funding/grants/policies/informedconsent/index.html >

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Graph Story 2

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Patients in any public or private hospital usually want to go back home quickly, as no one I believe really wants to stay in a hospital unless as Suresh Soni, chairman of the Bengaluru-based Nova Medical Centers, India said “you have a troublesome mother-in-law back home”.

“Patients stay on for longer not because they have to, but because the processes aren’t efficient enough”, says Avnish Bajaj, MD, Matrix Partners India.

A key metric often used by the healthcare industry to measure efficiency is average length of stay (ALOS). ALOS refers to the average number of days that patients spend in hospital. Hospitals calculate length of stay (LOS) data, which represents the number of calendar days that a patient was an inpatient. The total length of stay for all discharged patients is calculated for a given time period.  The ALOS is calculated by dividing the total LOS by the number of patients discharged. Day cases are excluded. In the calculation of ALOS, days and discharges of healthy babies born in hospitals are excluded in several countries (e.g. Australia, Austria, Canada, Chile, Estonia, Finland, Greece, Ireland, Israel, Japan, Korea, Luxembourg, Mexico, Spain, Sweden, Turkey).

Discharging patients as soon as possible is not so common in public hospitals in Malaysia unlike in most private hospitals in Malaysia and around the world.  But both public and private hospitals are just as keen on reducing overhead costs by discharging their patients as soon as possible.

In the rush to discharge patients as soon as possible means too short a length of stay which could  cause adverse effects on their health outcomes, or reduce the comfort and recovery of the patient. If this leads to a greater readmission rate, costs per episode of illness may fall only slightly, or even rise.

Although most hospitals would be keen on reducing overhead costs by discharging their patients as soon as possible, the more the revenue for the hospital when a patient stays longer in hospital,. Thus, a hospital’s revenue is proportionate to the average number of days a patient stays in it. Since services rendered vary each day of stay, the revenue may not be equal on every day of the stay of the patient; it will be high during the first few days and will wane gradually. According to Avnish Bajaj, a “hospital makes the most in the first 24 hours.”

It takes longer time for hospitals to start making profits as compared to other industries. You know that the longer you stay at a hotel, the more money the hotel makes. This is not the case in the healthcare business, it is the other way around.

Profit is the difference between the revenue from billing and cost incurred to render the service. A hospital’s revenue and costs are affected by various factors, such ALOS, occupancy level, in-patient and out-patient mix, and efficiency of personnel.

So hospitals aim to reduce the ALOS to a minimum of six days or less. However, shorter stays tend to be more service intensive and more costly per day. Since the revenue is higher during the first few days, reducing the ALOS to such a target may result in the effective utilisation of resources—the hospital can achieve higher occupancy levels with a reduced number of beds, collecting more revenue per patient per day than before. All other things being equal, a shorter stay will reduce the cost per discharge and shift care from inpatient to less expensive post-acute settings like to day care centres which “make so much business sense” also according to Avnish Bajaj.

Let’s get an impression from ALOS data of how we in Malaysia fare among the Organisation for Economic Co-operation and Development (OECD) countries. The graph below (click on the graph to view a large view of the graph in a new tab of your current window) shows the ALOS in hospital for all causes, 2000 and 2009 among OECD countries. Malaysia is a member country of OECD.

Graph credit : http://www.oecd-ilibrary.org/

At the exteme right of the bar graph, ALOS was lowest in Mexico, Turkey and Israel. It was also low in Norway and Denmark, as well as in the United States, all at less than five days. At the exteme left of the bar graph, the ALOS was highest in Japan, followed by Korea. In the center of the graph, notice that the OECD average is shown to be about 7 days.

The Ministry of Health Malaysia ALOS statistics for Malaysia in 2003 was 4.61 days and 4.25 days in 2009. So Malaysia is in the same space as Mexico, Turkey and Israel.

OECD reports that ALOS in Japan is higher than all other OECD countries because of the abundant supply of beds and the structure of hospital payments which provide hospitals with incentives to keep patients longer.

The use of less invasive surgical procedures, financial incentives inherent in hospital payment methods, and the expansion of early discharge programmes which enable patients to return to their home to receive follow-up care are some of the factors according to OECD that explain the decline in ALOS in e.g. Japan, Switzerland and the United Kingdom that had relatively high levels in 2000.

High levels of ALOS exceeding 12 days is indicative (Srinivasan  2008) of the presence of chronic or incurable patients in a hospital intended for acute care, poor medical care, hospital-acquired infection, lack of interdepartmental consultants, or bottlenecks in investigative procedures.

Health Information Management (HIM) / Medical Records (MR) practitioners are responsible for overseeing the process of collecting and verifying the statistics generated at all hospitals and compile statistics regarding admission, discharge, and LOS of patients.

ALOS of patients, death rates, autopsy rates, infection rates, and consultation rates are some of the commonly computed rates based on discharge statistics which is a group of hospital statistics calculated from data accumulated when patients are discharged.

Discharge statistics are used to analyse and monitor the hospital’s operations. Discharge statistics provide a benchmark upon which decisions are made to operate and manage the hospital.

References:
Health at a Glance 2011, OECD Indicators, Average length of stay in hospitals, viewed 15 October 2012 <http://www.oecd-ilibrary.org/docserver/download/fulltext/8111101ec033.pdf?expires=1350662961&id=id&accname=guest&checksum=8A568585D320449DE1B01658D38287AD>

Kripa M 2012, Outlook Business, The Specialists, 13 October 2012, Outlook Publishing (India) Pvt. Ltd., Mumbai, India

Ministry of Health Malaysia, Main MOH Publications, viewed 15 October 2012 <http://www.moh.gov.my/v/mmh>

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Srinivasan AV 2008, Managing a Modern Hospital,  2nd edn, SAGE Publications, New Delhi, India

Wager, KA, Frances WL & John PG 2005, Managing health care information systems : a practical approach for health care executives, 1st edn, Jossey-Bass,  San Francisco, CA, USA

JCI Standard MCI.20.1 – patient based data and aggregate data, in a process available to aggregate data to meet the needs of internal and external users

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Health data collection at hospitals is a responsibility of the health information department and  performed by Health Information Management (HIM) / Medical Records (MR) practitioners. It is common for hospitals to generate monthly and annual reports that describe the number of patients treated and the types of services delivered. The data to generate the monthly and annual reports are typically based on patient data relating to a single patient, such as his/her diagnosis, name, age, earlier medical history etc. from a single patient-health care worker interaction.

For instance, when a patient visits a hospital, a variety of details may be recorded, such as the patient’s temperature, their weight, and various blood tests. Should this patient be diagnosed as having “Vitamin B 12 deficiency anaemia, unspecified”, HIM/MR practitioners are all too familiar to code the diagnosis as corresponding to ICD-10 code D51.9, this particular interaction might eventually get recorded as an instance of “Anaemia” in an aggregate based system, that is reported in the monthly morbidity report, for example.

Patient based data is important when you want to track longitudinally i.e concerned with the development of patients over time. For example, if we want to track how a patient is adhering to and responding to the process of TB treatment in Malaysia (typically taking place over 6-9 months), we would need patient based data.

Aggregated data differs from patient based data.

It is the consolidation of data relating to multiple patients, and therefore cannot be traced back to a specific patient. They are merely counts, such as incidences of Malaria, TB, or other diseases. Typically, the routine data that a hospital deals with is this kind of aggregated statistics, and is used for the generation of routine reports and indicators, and most importantly, strategic planning within the health system. Aggregate data cannot provide the type of detailed information which patient level data can, but is crucial for planning and guidance of the performance of health systems.

HIM/MR practitioners know very well that patient data is highly confidential and therefore must be protected so that no one other than doctors can get it. For HIM/MR practitioners who continue to work with paper-based medical records, they are very aware that it must be properly stored in a secure place. For HIM/MR practitioners who choose to work with computers (EMRs/EHRs), they are aware that patient data needs secure systems with passwords and restrained access.

With the kind of introduction above laid out before you, I am going to write about the Joint Commission International (JCI) Standard MCI.20.1 which states that “The organization has a process to aggregate data and has determined which data and information are to be regularly aggregated to meet the needs of clinical and managerial staff in the organization and agencies outside the organization.”

JCI Standard MCI.201. has specific requirements.

The first requirement for JCI Standard MCI.20.1 is to ensure that hospitals as “The organization has a process to aggregate data in response to identified user needs.”

The second requirement is when the hospital as “The organization provides needed data to agencies outside the organization.”

Given the wide issues of concern for the above two requirements  I shall not rush to complete writing about JCI Standard MCI.20.1 for the sake of publishing on the web in a hurry while compromising the quality of the posts.

I like to say once again that what I am blogging about in posts like this one is simply a collection of my experiences and working knowledge accrued over the long years. I hope the posts I bring you in this blog convey best practices in HIM/MR which I hope young HIM/MR practitioners can learn to improve and the senior ones to compare, re-learn and adapt to bring HIM/MR practices to a higher level.

However, I am not implying what I am blogging here is all the gospel truth about standards to maintain or processes and procedures which need to be followed, as what I have written about are not carved in stone.

I ask you as the reader to make meaningful comments on posts I bring. I wish to continue to learn in the process and grow.

I shall post about the first requirement of the two requirements for this standard in my next post for this standard.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Risks, benefits, and alternatives of anaesthesia

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When devising a plan of anaesthesia care, the anaesthesia planning process includes educating the patient, his or her family, or decision maker on the risks, benefits, and alternatives related to the planned anaesthesia and postoperative analgesia.

Educating the patient, his or her family, or decision maker on the risks include the following factors to consider when formulating a planned anaesthetic,  usually hampered by individual patient variability:

  1. persuading patients who may express a fear of dying during anesthesia that anaesthesia is very safe (Ronald & Manuel, 2011)
  2. certain prescription drugs (antihypertensive, tranquilisers, steroids, and diuretics) and over-the-counter (OTC) medications and herbal preparations, can increase (Sue & Patricia, 2011) the patient’s anaesthesia risks. Surgical patients with chronic diseases at risk taking numerous medications can cause complications during the perioperative period and also increase the patient’s anaesthesia risks. The anaesthesiologist will advise the patient, family, and decision makers which medication(s) must be stopped at least 2 weeks prior to surgery, or the surgery may be canceled.
  3. the patient’s co-morbid conditions i.e coexisting diseases
  4. other risks include peripheral nerve damage, brain damage, airway trauma (most often caused by difficult tracheal intubation), intraoperative awareness, eye injury, fetal/newborn injury, and aspiration.

The use of regional anaesthesia has significant benefits for patients and facilities. For example, regional anaesthesia  for patients undergoing orthopedic procedures decreases (Ronald & Manuel, 2011) overall anaesthesia when compared to general anaesthesia and postanaesthesia care unit (PACU) discharge time can be shortened and the immediate postoperative period made more pleasant for the patient.

The patient, his or her family, or decision maker  will be educated on the choice of anaesthesia, whether it is to be either general, or regional or sedation and will be influenced by (Ronald & Manuel, 2011):

  1. site of the surgery
  2. position of the patient during surgery
  3. risk of aspiration
  4. age of the patient
  5. patient cooperation
  6. anticipated ease of airway management
  7. coagulation status
  8. previous response to anaesthesia
  9. preference of the patient

This discussion on the risks, benefits, and alternatives related to the planned anaesthesia and postoperative analgesia occurs as part of the process to obtain consent for anaesthesia (including moderate and deep sedation) as required in PFR.6.4, ME 2, which I have already blogged about in the post Informed Consents – 5 required documentation in the medical record providing information to patient and family  (this link will open in a new link of your current window).

An anaesthesiologist or a qualified individual provides this education.

If a hospital has been accredited for Joint Commission International (JCI) accreditation status or already enjoying JCI accreditation status or because a hospital is going for a re-survey by JCI surveyors for another new term of JCI accredited status, then a Health Information Management (HIM) / Medical Records (MR) practitioner is likely to be part of a team using the Medical Records Review Tool form during any one Medical Records Review session which contains the JCI Standard ASC.5.1 to test for conformance to its requirement which states that “The risks, benefits, and alternatives are discussed with the patient, his or her family, or those who make decisions for the patient.”

Although this standard does not require any form of documentation in the medical record, HIM/MR practitioners must take note that risks, benefits, and alternatives that are discussed with the patient, his or her family, or those who make decisions for the patient are normally recorded by the surgeon or anaesthetist in the Preanaesthesia Evaluation Note.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Ronald, DM & Manuel, CP Jr 2011, Basics Of Anesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA