ACC.4.4 |

Patients may be transferred within the hospital during their care or to other settings outside of the hospital based on status and the need to meet their continuing care.

Let us consider the case of a patient who is transferred within the hospital. In this instance, the care team changes and so essential information related to the patient needs to be transferred with him or her to facilitate continuity of care for this patient. Thus, medications and other treatments for this patient can continue uninterrupted, and the patient’s status can be appropriately monitored.

What Health Information Management (HIM) / Medical Records (MR) practitioners need to know is in order to accomplish this information transfer when a patient is transferred within the hospital., the patient’s medical record(s) is transferred or information from the patient’s medical record is summarised at transfer as shown in the graphics below. 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, then this specific requirement is as stated for JCI MCI.8 which states that “Information related to the patient’s care is transferred with the patient.”

Another point to take note by the general reader is when a patient is transferred to other settings outside the hospital, the transfer process is documented in the patient’s medical record including documentation of any change in patient condition or status during transfer just as in the case for a patient transferred within the hospital, as I had posted in the post 5 transfer process entries that must be entered in a medical record (this link will open in a new tab of your current browser window).

I like to conclude that I think it is appropriate for HIM / MR practitioners who work at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, to take note that transfers within a hospital or to outside the hospital is covered by 1 standard under the Management of Communication and Information (MCI) chapter and by 5 JCI standards under the Access to Care and Continuity of Care (ACC) chapter respectively from the JCI Accreditation Standards For Hospitals, 4th Edition.

References:

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

A patient might require a hospital transfer for a number of reasons. The patient or the family might want a second opinion, the current hospital cannot address the needs of the patient, or the new hospital offers more advanced care among other reasons.

When a patient is transferred to another hospital or health care organisation, the transfer process is documented in the patient’s medical record.

A HIM/MR professional needs to be aware of five transfer process entries which must be included in a medical record when a patient is transferred to another hospital or health care organisation.

These 5 transfer process entries as documented in the medical record will state and/or contain :

the name of the hospital or health care organisation and name of the individual agreeing to receive the patient
any documentation or other notes as required by the policy of the transferring hospital for example, a signature of the receiving nurse or physician, name of the individual who monitored the patient during transport
the reason(s) for transfer
any special conditions related to transfer such as when space at the receiving hospital or health care organisation is available, or the patient’s status
any change in patient condition or status during transfer for example, the patient dies or requires resuscitation

If your hospital is in the process of becoming a Joint Commission International(JCI) accredited hospital, you need to know that the JCI Standard ACC.4.4 requires that a transfer process from one hospital(health care organisation) includes the above mentioned 5 transfer process entries in the patient’s medical record.

However, do take note that the JCI Medical Records Review Tool does not list documentation required by policy requirements of the transferring hospital, as one of its measurable elements.