Never miss out an adverse event in the medical record!

Posted on 19/12/2013 by admin

A hospital will normally have a policy that identifies all adverse effects that are to be documented in a medical record and those that must be reported to the hospital’s authorities within a specified time frame. An adverse event is defined as “an unanticipated, undesirable, or potentially dangerous adverse effect occurrence” in a hospital (JCI ASH p.246).

Patients are reassessed to determine their response to treatment on medications since they may suffer adverse effects like allergic responses, unanticipated drug/drug interactions, or a change in their equilibrium raising their risk of falls. Therefore, patients are constantly monitored for medication effects including adverse effects through the collaborative efforts between patients themselves, their doctors, nurses, and other health care practitioners (i) to evaluate the medication’s effect on the patient’s symptoms or illness, as well as blood count, renal function, liver function, and other monitoring with select medications, (ii) to observe the patient for adverse effects, and (iii) to record in the patient’s medical record any adverse effect(s).

This monitoring process is normally a proactive approach to risk management of a hospital with a formalised program of risk management to investigate and to reduce identified, unanticipated adverse events and other safety risks to patients and staff.

The accreditation process is well known as an effective quality evaluation and management tool designed to create a culture of safety and quality within a hospital. One of the benefits of accreditation is it strives to continually improve patient care processes and results.

If your hospital is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then the basics of data gathering and preparation includes selection of measures, data collection and aggregation, data analysis and interpretation, dissemination/transmission of findings, taking action, monitoring performance/improvement are all integral to improving safety and quality of care at your hospital. Medication management data collection issues are either addressed during the System Tracer (Data Use) as a shorter survey or during the full System Tracer – Medication Management survey.

I like to draw your attention when individuals like you as a Health Information Management (HIM) / Medical Records (MR) practitioner may be roped in as part of the hospital’s group of participants during the System Tracer (Data Use) survey since you could be considered as “Individuals who are knowledgeable about the information systems available for data collection, analysis, and reporting” (JCI HSPG p.74) or excluded if a shorter survey just for medication management data collection issues are to addressed.

Do take note too that if you are at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, the Medical Record Review Tool (MMRT).will now check for compliance of the JCI Standard MMU.7 which states that “Medication effects on patients are monitored.”, which this post is all about.

Readers, this post on the JCI Standard MMU.7 and all the rest of the standards I have posted using the JCI Hospital Accreditation Standards 4^th Edition, concludes all of the necessary and mandatory documentation standards that must be included in a complete medical record. For hospitals not yet on the JCI journey, I think applying all the standards that are mandatory documentation standards using the JCI Hospital Accreditation Standards 4^th Edition augurs for high quality medical records documentation standards at any hospital.

References:

Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals (ASH), 4th edn, JCI, USA
Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA

JCI Standard MCI.4 – accuracy and timeliness of information in the hospital through effective communication

Posted on 13/11/2013 by admin

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

End-of-life issues, what you need to document in the medical record

Posted on 22/10/2013 by admin

Image credit : National Institutes of Health, USA

Assessment findings guide the care and services to be provided by all the patient’s health care practitioners, including the doctor and/or nurse. The findings are then normally documented in the patient’s medical record.

Likewise, reassessment by a doctor are also documented in the patient’s medical record. I had posted about the need to document reassessment into the patient’s medical record as defined in organisation policies and procedures for thirteen (13) situations in the post Reassessment of all patients and results are always entered in their medical records (this link will open in a new tab of your current browser window), the thirteenth situation been when dying patients and their families are assessed and reassessed according to their individualised needs by evaluating and managing their symptoms and preventing complications to the extent reasonably possible in the care of these dying patient to optimize his or her comfort and dignity.

When patients are at the end of life, these dying patients including their families or indeed anyone else actually connected with the patient are then assessed and reassessed to identify the patients’ and families’ needs, i.e end-of-life issues. Assessments and reassessment are carried out to evaluate the patient’s condition such as symptoms of nausea and respiratory distress and to identify factors that seem to alleviate or exacerbate the physical symptoms, the patient’s current symptom management and the patient’s response.

Thus the medical record of a dying patient should contain documentation on symptoms like nausea and respiratory distress and whatever factors that are alleviating or exacerbating these physical symptoms.

Also to be found in the medical record of a dying patient will be documentation on assessments on both the patient’s and family’s individualised needs including evaluations to record the following :

spirituality – it would be much more difficult to anticipate the spiritual needs of a patient and family from a culture unfamiliar to you, so better understand what is the patient’s and the surrounding family members’ dominant religion and views regarding the meaning and purpose of life and, as appropriate, any involvement to a religious group and what are their spiritual concerns or needs, such as despair, suffering, guilt, or forgiveness, thus the need to work within the patient’s and the patient’s family cultural belief system by hearing the patient and his or her family and the patient’s daily experiences; culturally based care i.e transcultural nursing according to Madeleine Leininger who was a nursing theorist, nursing professor and developer of the concept of transcultural nursing, contributes to healing (health), well-being, and helping patients who face dying or death
their psychosocial status, such as family relationships, the adequacy of the home environment if care is provided there, coping mechanisms
the patient’s and family’s reactions to illness since the patient will experience significant loss as a result of the health alteration when recovery from illness is incomplete; as a result many people (patient and/or family) may direct that anger towards health-care personnel because they have no control over the situation already as the loss begins to sink in but when finally, the patient and family come to terms with the loss, they will begin making plans for the future
the need for support or respite services with the challenges of caring for the dying by the caregiver(s)
the patient’s need or request from the patient’s family for, an alternative setting or level of care
any survivor risk factors, such as family coping mechanisms and the potential for pathological grief reaction

The above documentation requirements in a medical record of a dying patient are required more so if you as a Health Information Management (HIM) / Medical Records (MR) practitioner manage such medical records in a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, when your hospital will need to fully comply with the JCI Standard AOP.1.9 which states that “Dying patients and their families are assessed and reassessed according to their individualized needs.” The three (3) Measurable Elements of Standard AOP.1.9 will be measured through the Medical Record Review Tool (MMRT).

Medical records documentation of dying patients is not just to comply with an accreditation body like the JCI. The filing of the medical record about end-of-life concerns about the amount of information which might be submitted within the medical record which will then be subject to scrutiny irrespective of whether that scrutiny included any authorised investigatory agency. Although a doctor may believe that he or she may not have done nothing wrong, he or she will fear the process of investigation of deaths (Stephen 2012), under a death reporting system.

As a diversion to end-of-life issues, medical records of a not-dying patient, Hilly Boscher from the Netherlands is worthy of mention when in the Chabot case (Stephen 2012), a psychiatrist named Chabot helped this patient to die who was NOT terminally ill i.e NOT a dying patient. In this case, she (Hilly) had been suffering from grief as a result of losing both of her children. Dr Chabot diagnosis was : ‘an adjustment disorder consisting of a depressed mood, without psychotic signs, in the context of a complicated bereavement process’. Hilly had refused all anti-depressants and bereavement counselling. However, Chabot was not convicted by the Dutch Supreme Court on the ground that (Stephen 2012 p.288) “there was no requirement that suffering is terminal or physical”. My point is, seven (7) other psychiatrists had examined her medical records and had agreed with Chabot’s diagnosis, so do you agree that there is the greater need for greater detail in medical records documentation in the case of a dying patient?

References:

Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA
Stephen, WS 2012, End-of-Life Decisions in Medical Care Principles and Policies for
Regulating the Dying Process, Cambridge University Press, Cambridge, United Kingdom
Pamela, MS & Linda, N 2010, Communication for nurses : how to prevent harmful events and promote patient safety, F. A. Davis Company, Philadelphia, PA, USA

Must medical records show evidence of specialised assessments?

Posted on 02/09/2013 by admin

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

Periodicity Of Reassessments For 13 Situations Found In Medical Records

Posted on 26/04/2013 by admin

Here is a graphic to show a summary of the periodicity of reassessments in 13 situations which can be found in a medical record. Click the image to view a larger image in a new tab of your current window.