Category Archives: AOP.2

Never miss out an adverse event in the medical record!

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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 4th 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 4th Edition augurs for high quality medical records documentation standards at any hospital.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals (ASH), 4th edn, JCI, USA
  2. 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

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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:

  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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:

  1. Dale, EB & Daena, JG (eds.) 2009, Communicating to manage health and illness, Routledge, London, UK
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
  4. Sheila, P & Sandra, H (eds.) 2007, Health communication Theory and practice, Open University Press, McGraw-Hill Education, England, UK

Periodicity Of Reassessments For 13 Situations Found In Medical Records

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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.

Periodicity-Of-Reassessments-For-13-Situations-Found-In-Medical-Records

Reassessment of all patients and results are always entered in their medical records

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Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware of the evidence of reassessment of all patients and results which are always entered in patients’ medical records. The results of these reassessments noted in the patient’s medical record is for the information and use of all those caring for the patient.

Health care practitioners  – predominately doctors and nurses are the ones who routinely conduct reassessment of patients in the following situations:

  1. to determine the patient’s response to treatment and whether the intervention remains appropriate
  2. to plan for continued treatment or discharge
  3. at intervals based on a patient’s condition and when there has been a significant change in his or her condition, plan of care, and individual needs or according to organisation policies and procedures

HIM / MR practitioners also need to be aware that a reassessment is integral to ongoing patient care i.e. it is a continuous process, and it is the key to understanding whether care decisions are appropriate and effective, and are normally carried out at intervals based on the patient’s condition and treatment to determine their response to treatment and to plan for continued treatment or discharge.

However, the periodicity of reassessment depends on the condition as well as a patient’s needs extending to the plan for continued treatment or discharge, or as defined in organisation policies and procedures as in the following situations:

  1. acute care patients are reassessed by the doctor(s) at least daily, including weekends, and when there has been a significant change in the patient’s condition
  2. non-acute patients maybe assessed less than daily and determined by a hospital policy which defines the circumstances in which, and the types of patients or patient populations for which, a doctor identifies the minimum reassessment interval for these patients
  3. nursing staff may be observed to periodically record vital signs as needed based on the patient’s condition in response to a significant change in the patient’s condition
  4. if the patient’s diagnosis has changed and the care needs require revised planning
  5. to determine if medications and other treatments have been successful and the patient can be transferred or discharged
  6. the care of patients undergoing moderate and deep sedation especially the frequency and type of patient-monitoring requirements
  7. the minimum frequency and type of monitoring during anaesthesia which is written into the patient’s anaesthesia record
  8. monitoring of physiological status during anaesthesia administration which is written into the patient’s anaesthesia record
  9. the patient’s physiological status is monitored during surgery and immediately after surgery
  10. the patient’s readiness for discharge based on the patient’s current reassessed health status and need for continuing care or services as determined by the use of relevant criteria or indications from a referral and/or discharge plan begun early in the care process and, when appropriate, which had included the family to ensure patient safety
  11. the collaborative monitoring process on medications by doctors, nurses, and other health care practitioners when they jointly evaluate the medication’s effect on the patient’s symptoms or illness and monitor and report for adverse effects like allergic responses, unanticipated drug/drug interactions, or a change in the patient’s equilibrium raising the risk of falls among others, thus in both cases to allow the dosage or type of medication to be adjusted when needed
  12. when patients are been monitored to their response to a collaborative plan among doctors, nurses, the dietetics service, and, when appropriate, the patient’s family, to provide nutrition therapy after a screening process during an initial assessment to identify those at nutritional risk
  13. 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

As I researched for this post, I found that this is the NOT the last in the list of medical record documentation requirements I have found as required by the Joint Commission International (JCI) standards for documentation required in a medical record.

I will still need to discuss on these other medical record documentation requirements:

  1. when a hospital policy identifies adverse effects that are to be recorded in the patient’s record and those that must be reported to the hospital
  2. when the patient’s response to nutrition therapy is recorded in his or her record
  3. when assessments and reassessments need to be individualised to meet patients’ and families’ needs when patients are at the end of life, and assessment findings are documented in the patient’s medical record

Nonetheless, any hospital’s medical record documentation, irrespective if the hospital had undergone the journey to JCI accreditation or is planning to do so, all of which will contain reassessment findings recorded in them, including that related to needs when patients are at the end of life.

So if you are practising at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then your hospital will need to fully comply with the JCI Standard AOP.2 which states that “All patients are reassessed at intervals based on their condition and treatment to determine their response to treatment and to plan for continued treatment or discharge.” Documentation of reassessment of patients in their medical records also satisfies the JCI Standard MCI.19.1, Measurement Element 5 requirement which states that “Patient clinical records contain adequate information to document the course and results of treatment.”.

References:

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