Let’s assume that you as a Health Information Management (HIM) / Medical Records (MR) practitioner, work in a hosptial that is actively undergoing an accreditation program for quality assurance, and your hospital is adopting the Joint Commission International (JCI) acrreditation program.
During the survey process when your hospital is undergoing the JCI acrreditation program, surveryors may request a closed medical record review session.
As a HIM / MR practitioner in such a hospital setting, you need to know that a sample of your medical records will be used for this closed medical records review session, and you must be aware of the reason why those records are reviewed and what the surveyors are looking for in them.
The surveyors will check for compliance on JCI standards, and one of them is the JCI Standard AOP.1.5 as listed in the Closed Medical Records Review Form (i.e JCI Standard AOP.1.5 is one of the JCI standards included in the list of standards in this form).
JCI Standard AOP.1.5 states that “Assessment findings are documented in the patient’s record and readily available to those responsible for the patient’s care.”
The Closed Medical Records Review Form is used to gather and document complainance wth the JCI Standard AOP.1.5 which is one of the JCI standards that require documentation in the patient’s medical record.
If you read about the post Medical documentation in medical records of initial medical and nursing assessments on initial medical and nursing assessments, initial assessments and continuous assessment findings are used throughout the care process to evaluate patient progress and to understand the need for reassessment. If all medical and nursing assessments from the initial instance and throughout the patient’s stay at the hospital is documented well in the patient’s medical record, then your hospital certainly complies well with the JCI Standard AOP.1.5, ME 1 which states “Assessment findings are documented in the patient’s record.”
If your medical, nursing, and other meaningful assessments are documented well and can be quickly and easily retrieved from the patient’s record or other standardised location and used by those caring for the patient, then the surveyors and certainly your hospital’s management will be happy that your hospital passes the JCI Standard AOP.1.5, ME2 which states “Those caring for the patient can find and retrieve assessments as needed from the patient’s record or other standardized accessible location.”
Doctors and nurses must ensure that the patient’s medical and nursing assessments are documented in the record within the first 24 hours of admission as an inpatient.
This does not preclude the placement of additional, more detailed assessments in separate locations from the patient’s record as long as they remain accessible to those caring for the patient. If this is done within this stipulated time frame, then your hospital also complies with the JCI Standard AOP.1.5, ME 3 and ME 4 which state respectively “Medical assessments are documented in the patient’s record within 24 hours of admission.” and “Nursing assessments are documented in the patient’s record within 24 hours of admission.”
References:
Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
