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My intention in bringing this post to a Health Information Management (HIM) / Medical Records (MR) practitioners reader specifically and to all other readers in general, is to understand the dynamics of communication and your role in managing patient-specific information in a hospital setting when the leaders of the hospital agree to an essential condition whereby effective communication must prevail among and between professional groups; structural units, such as departments; between professional and non-professional groups; between health professionals and management; between health professionals and families; and with outside organisations.

In making this agreement for effective communication throughout the hospital setting, I agree the stipulations that this issue is primarily a leadership function of the hospital’s leaders. This agreement is stipulated in the Joint Commission International (JCI) Standard MCI.4 which states that “Communication is effective throughout the organization”, especially so if you are practising in a hospital accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

The reader as a leader of a structural unit setting and relevant service needs to be aware of the following conditions in this agreement for effective communication:

for patient care to appear seamless, processes must be in place for communicating relevant information in an accurate and timely manner throughout one’s structural unit, such as the HIM / MR department and between other structural units in the hospital; this is to ensure that the processes are designed and implemented to support continuity and coordination of care as patients move through the hospital from admission to discharge or transfer, several departments and services and many different health care practitioners may be involved in providing care; for example from emergency services to inpatient admission
the hospital defines the patient-specific information, example patient’s weight and other physiological information available from the medical record, required for an effective review process and is facilitated by a record (profile) i.e via medication administration records (MAR) or medication list, also to be found within a medical record for all medication administered to a patient except emergency medications and those administered as part of a procedure; the medical record folder is updated after a review of a patient receiving medications, example the folder is tagged with an alert sticker for allergies or sensitivity; this review also facilitates the medication reconciliation process across the continuum of care and the process continues upon discharge and transfer of the patient, and the complete list of patient medications is shared with the next provider of patient care
effective communication occurs in the hospital among the hospital’s programs ranging from the emergency services, inpatient admission, diagnostic services and treatment services, surgical and non-surgical treatment services and outpatient care programs for seamless care
since patients frequently require follow-up care to meet on-going health needs or to achieve their health goals, there is a plan by the hospital’s leaders with the leaders of other health care organisations in its community for effective communication to occur between the leaders of these other health care organisations in its community during referrals; the plan establishes contact with known resources i.e. the patient’s home community and identified specific individuals and agencies that are most associated with the hospital’s services and patient population in order that they help support continuing health promotion and disease prevention education
there are policies and procedures developed to support and to promote patient and family participation in care processes to ensure that continuity and coordination are evident to the patient; effective communication thus occurs with patients and families in these circumstances:
1. patients and families are involved in care decisions by effective communication thus occurs with patients and families when (i) they understand how and when they will be told of planned care and treatment(s), (ii) understand their right to participate in care decisions to the extent they wish and learn about how to participate in care decisions
2. inpatients and outpatients who leave against medical advice when patients, or those making decisions on their behalf, may decide not to proceed with the planned care or treatment or to continue care or treatment after it has been initiated guided by a process for the management and follow-up of such cases
3. effective communication thus occurs with patients and families when those who provide education encourage patients and their families to ask questions and to speak up as active participants
4. effective communication occurs with patients and families when indicated, planning for referral and/or discharge begins early in the care process ie. soon after admission as inpatients and, when appropriate, includes the family
5. effective communication occurs with patients and families when patients are reassessed to plan for continued treatment or discharge
6. effective communication occurs with patients and families such that symptoms and complications are prevented to the extent reasonably possible during the care of the dying patient
and finally. the reader as a leader must not only set the parameters of effective communication but also serve as role models with effective communication of the hospital’s mission and appropriate policies, plans, and goals to all staff.

I acknowledge the role of effective communication and its pervasiveness in creating, gathering and sharing health information in meeting challenges and improving health care outcomes. In this post, I think I have achieved to address some pertinent issues relevant to effective communication when implementing the requirements of the JCI Standard MCI.4 specifically and also delving into the issues of effective communication in general.

References:

Dale, EB & Daena, JG (eds.) 2009, Communicating to manage health and illness, Routledge, London, UK
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
Sheila, P & Sandra, H (eds.) 2007, Health communication Theory and practice, Open University Press, McGraw-Hill Education, England, UK

Let’s look at a simplified diagnostic process from the diagram below, when hearing, visual and dental tests are three common screening tests during the initial assessment during the review of the complaint, history and physical when the patient arrives with complaint at a hospital.

Diagram credit: Kenneth, RW & John, RG 2010, The well-managed healthcare organization, 7th edn, Health Administration Press, Chicago, Illinois, USA

Auditory testing performed during an initial assessment is usually done with a tuning fork. Tests using a tuning fork are meant for screening only and never used for diagnostic purpose. Auditory testing provides the examiner during initial assessment with a basic idea of whether the patient has for example, a hearing loss. Thus, such a test simply provides an indication of the need for more elaborate testing and referral to a hearing specialist for more accurate testing if a problem is suspected.

Assessment of vision examines both visual acuity and anatomic structures. If you wear glasses, you had your visual acuity tested with the Snellen chart, a chart that contains various-sized letters with standardised numbers at the end of each line of letters. Visual acuity of 20/20 is considered normal. Astigmatism, hyperopia (farsightedness), myopia (nearsightedness) and presbyopia (farsightedness) are common vision related conditions. Assessment of eye structures and function present significant findings and possible causes for condtions like nystagmus and cataracts.

Another initial assessment is the assessment of the mouth, throat, nose, and sinuses which usually follows the examination of the head and neck. Examination of the mouth and throat can help detect abnormalities, for example of the lips. Early detection of oral cancer during an oral examination is an important finding. A deviated septum or detection of sinus infection are two other conditions that maybe detected during this kind of examination. Overall, the patient’s nutritional and respiratory status is also assessed.

From the diagram above, treatment is usually begun once the diagnosis is confirmed by the attending doctor, the initial caregiver. Sometimes, the initial assessment process may identify a need for other assessments. Thus, patients maybe referred and/or discharged based on their health status and needs for continuing care by other specialised health care providers to support their continuing continued care and learning needs. Patients are referred within the hospital or discharged from the hospital to a health care practitioner outside the hospital, another care setting, home, or family when the additional specialised assessment is identified during the initial assessment.

Health Information Management (HIM) / Medical Records (MR) practitioners must take note that specialised assessments conducted within the hospital should be documented in the patient’s medical record. Medical records documentation must show evidence of specialised assessments conducted within the hospital, especially so if you work at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, when the JCI Standard AOP.1.10 which states that “The initial assessment includes determining the need for additional specialized assessments.” requires complete documentation in the patient’s medical record of the need for additional specialised assessments conducted within the hospital.

References:

Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Kenneth, RW & John, RG 2010, The well-managed healthcare organization, 7th edn, Health Administration Press, Chicago, Illinois, USA
Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA