Category Archives: JCI Standards AOP

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

Posted on by
Reply

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

The need for discharge planning and discharge planning documentation

Posted on by
Reply

The attending doctor is responsible for a patient’s care and determines the patient’s readiness for discharge based on the policies and relevant criteria or indications of referral and discharge established by the hospital policy guiding the referral or discharge of patients .

Referring or discharging a patient to a health care practitioner outside the hospital, another care setting, home, or family is based on the patient’s health status and need for continuing care or services.

Continuity of care requires special preparation and considerations for some patients, such as for discharge planning.

Discharge Planning is a process which is initiated as soon as possible upon inpatient admission, that is during the initial assessment which includes determining the need for patients for whom discharge planning is critical due to age, lack of mobility, continuing medical and nursing needs, or assistance with activities of daily living, among others.

The discharge planning process includes a mechanism to identify those patients for whom discharge planning is critical. A discharge planning worksheet is generated based on a list of criteria and used as an assessment tool by a case manager or an utilisation manager (if there is one at your hospital, or in most instances initiated by a nurse), to identify patients who may require post-hospital services on discharge for inpatients once their acute phase of illness has passed. This worksheet is used to develop the Case Management Note which is a progress note documented by the case manager or an utilisation manager (if there is one at your hospital, or in most instances by a nurse),which outlines a discharge plan that includes case management/social services provided and patient education.

Discharge planning involves discussions on discharge plans with patients and their families on admission and during the hospital stay. A discharge plan is prepared to help determine home needs, assist in planning for needed medical equipment, helps in choosing a facility for care if the patient is unable to return home, and facilitates discharge to home or transfer to another facility.

The Case Management Note is not the same document as the Discharge Note which is the final progress note documented by the attending doctor, which includes details like the patient’s discharge destination (e.g., home), discharge medications, activity level allowed, and follow-up plan (e.g., office appointment).

Health Information Management (HIM) / Medical Records (MR) practitioners do take note that Health Information Management / Medical Records Management services does not include Discharge Planning. However HIM / MR practitioners can expect to find a Case Management Note included in some patients’ medical records.

HIM / MR practitioners who are members of a closed Medical Record Review, need to be aware that the Medical Record Review Tool will assess and determine the degree of compliance with standards and elements of performance relating to discharge planning given to some patients as required by the Joint Commission International  (JCI) Standard AOP.1,11 which states that “The initial assessment includes determining the need for discharge planning.”, if you are working at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

I like to point out that the Medical Record Review Tool has an error that shows the JCI Standard AOP.1.8.1 (Early screening for discharge planning) as found in the JCI Hospital Survey Process Guide, 3rd Edition, Effective January 2008 instead of showing the JCI Standard AOP.1,11 with regards to compliance in discharge planning. You can find my corrected version of this JCI recommended Medical Record Review Tool from this link (the form will open in a new tab of your current window).

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

6 steps in documenting hospital screening to identity patients with nutritional or functional needs

Posted on by
Reply

If you have been part or will be part of a Medical Records Review team at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, you will be surprised how so many of the team members do not know the reason for nutritional screening which is the start of the the Nutrition Care Process – even among nurses in the team, and most will even not know where to find such evidence of nutritional screening in the medical record. Most of times, poor documentation in relation to the quality of nutrition documentation can be observed when nutritional screening data is not even gathered and forms left not filled appropriately.

In my opinion, it is the duty of the Medical Records Review team leader to highlight in his or her report non-compliance to nutritional screening among other findings, so that the hospital’s leaders can initiate a structured investigation to identify barriers to compliance for nutritional screening. I also strongly support that there must be an agreed standard for the type and context of screening tool(s) to be used, for example among a group of hospitals under an organisation. I believe standardisation facilitates research into barriers leading to poor documentation in relation to the quality of nutrition documentation, and this will lend credibility and usability of available screening tools for greater compliance.

Below is a diagram which summarises the steps in documenting hospital screening to identity patients with nutritional or functional needs, based on the previous post Hospital screening criteria data to identify patients with nutritional or functional needs (this link will open in a new tab of your current browser).

6 Steps In Documenting Hospital Screening To Identify Patients With Nutritional Or Functional Needs

Hospital screening criteria data to identify patients with nutritional or functional needs

Posted on by
Reply

Patient medical records should show evidence that information on nutritional status or functional status is gathered through the application of screening criteria, when patients who are acutely or chronically unwell and who are experiencing dietary difficulties and deficiencies related to or resulting from their illness, first contact hospital services.

From the post Assessments within 24 hours (this link will open in a new tab of your current browser), it is clear that the initial medical and nursing assessments are completed within 24 hours of admission to the hospital  or when the patient’s condition indicates, the initial medical and/or nursing assessment are conducted and available earlier, for use by all those caring for the patient. This means that patients are screened for nutritional risk as part of the initial assessment with the application of screening criteria to gather information on nutritional status or functional status which is often done by nurses, must also be completed routinely within 24 hours of admission to the hospital or at an earlier time period.

Nutritional screening is usually undertaken by nurses and doctors; assessment by dietitians.

GETTY_H_062112_WeightScale

Image credit: abcnewsradioonline.com

Nurses use individual hospital screening criteria to identify patients with nutritional or functional needs like:

  • unexpected weight loss
  • gastrointestinal symptoms
  • obvious emaciation
  • pressure ulcers
  • intravenous or tube feedings

In each case, the screening criteria are developed by qualified individuals with the aim to identify those who are malnourished or ‘at risk’ of becoming so and so able to further assess and, if necessary, to provide any required patient treatment. For example, screening criteria for nutritional risk may be developed by nurses who will apply the criteria, dietitians who will supply the recommended dietary intervention, and nutritionists able to integrate nutritional needs with the other needs of the patient.

Referencing of all tools available and screening criteria used  is beyond the scope of this single post. However, I like to share with you the desirable qualities of such tools used to carry out the screening which are namely (i) accuracy of the tool(sensitivity and specificity), (ii) easy to use, (iii) reliable so as to produce similar results with repeat testing in the same circumstances and with different users where the patient’s state has not changed it must be acceptable to those being screened, (iv) does not require extensive training, and (v) does not need additional equipment.

For your information too, two commonly used tools developed for hospital-wide application and used with older adults are (i) Mini Nutritional Assessment (MNA), and (ii) Malnutrition Universal Screening Tool (MUST).

Information through these kinds of screening criteria tools provides insight into the patient’s overall physical health. The information may also indicate that patients at risk for nutritional problems according to the criteria, receive further or more in-depth assessment of nutritional status or functional status, including a fall-risk assessment.   This information is viewed as the most effective way and an essential first step in the management of patients’ nutritional care.

The more in-depth assessment mentioned above may be necessary to identify the problem or potential nutrition risk(s) for those high risk patients in need of nutritional interventions and patients in need of rehabilitation services or other services related to their ability to function independently or at their greatest potential. Nurses refer these patients in need of a functional assessment according to the criteria to the hospital Dietitian for full nutrition assessment.. The dietitian will usually first review the medical record of referred patients. Everything from diagnosis, social history, medical history, medication, laboratory data and assessment, and evaluations performed by other medical/clinical personnel are scrutinised  According to Jacqueline (2011), reading the medical record which contains the notes of other clinicians provides necessary context for effective management of the condition(s) being assessed. A dietitian may then take anthropometric measurements in addition to a subjective nutritional assessment.

Subjective data pertaining to the nutritional assessment, identify abnormal findings and client strengths which could include for example, Patient A who is a female, stated age 42 years; reports she had a fever for 2 days a week ago; drinks 4 to 6 glasses of water daily) and anthropometric measurements i.e the objective data could include for example, Height: 5 feet, 5 inches (165 cm); body frame: medium; weight: 128 lb (58 kg); BMI: 21.3). The data is usually clustered to reveal any significant patterns or abnormalities. These data may then be used to make clinical judgments about the status of the patient’s nutritional health.

At this point, I like you to take note that the dietitian uses assessments techniques which vary for the mother and unborn child as well as the complications associated with pregnancy, the lactating mother, infants and children.

Once the dietitian has a a clear understanding of the medical diagnosis and its nutritional implications, intervention is initiated, the patient is carefully monitored to ensure that goals are met and the desired outcome is achieved.

Do take note that if you are working at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, your hospital will need to comply with JCI Standard AOP.1.6 which states that “Patients are screened for nutritional status and functional needs and are referred for further assessment and treatment when necessary.”

I am sure you are already aware that your hospital has in place a program which evaluates its patients’ risk for falls – which could include fall history, medications-and-alcohol-consumption review, gait and balance screening, and walking aids used by the patient, and monitors both the intended and unintended consequences – for example, the inappropriate use of physical restraints or fluid intake restriction which may result in injury, impaired circulation, or compromised skin integrity of measures, taken to reduce falls.

JCI believes that compliance to JCI Standard AOP.1.6 as part of the initial assessment using criteria developed by qualified individuals to identify patients who require further functional assessment, further strengthens a hospital’s fall-risk reduction program.

It is common in hospitals when patients are provided dietetic services after dietary orders by the doctor attending are documented in the patient medical record. Health Information Management (HIM) / Medical Records (MR) practitioners will find within medical records, progress notes with the nutritional care of the patient met in accordance with the doctor’s orders and also the Dietary Progress Note, a progress note documented by the hospital dietitian as part of recognised dietary practices which includes:

  • patient’s dietary needs
  • any dietary observations made by staff (e.g., amount of meal consumed,food likes/dislikes, and so on)

HIM / MR practitioners who are members of a closed Medical Record Review, need to be aware that the Medical Record Review Tool will assess and determine the degree of compliance with standards and elements of performance relating to nutrition care given by the JCI Standard AOP.1.6, when there is evidence in the medical record of patients screened for nutritional status and functional needs.

References:

  1. Jacqueline, CM, 2011, Detitian’s guide to assessment and documentation, Jones and Bartlett Publishers, Sudbury, MA, USA
  2. Janet, W, & Jane HK, 2010, Health assessment in nursing, 4th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, PA, USA
  3. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  4. Nutritional screening and assessment, Nursing Times.net, viewed 17 February 2013, < http://www.nursingtimes.net/nutritional-screening-and-assessment/199381.article >
  5. Using nutritional screening tools to identify malnourished patients, Nursing Times.net, viewed 17 February 2013, < http://www.nursingtimes.net/nursing-practice/clinical-zones/nutrition/using-nutritional-screening-tools-to-identify-malnourished-patients/1958881.article >
  6. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
  7. Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Medical and Nursing assessments in 24 hours, updates if less than 30 days old

Posted on by
Reply

My purpose of writing this post is to highlight that the Medical Records Review Tool (MMRT) form contains a provision to check for compliance to “Medical assessment in 24 hours. Updates if less than 30 days old. Nursing assessment in 24 hours” documentation in a medical record during a Medical Records Review (MMR) session.

Members of a MMR session must be able to connect this provision found in the MMRT form to the Joint Commission International (JCI) Standard AOP.1.4.1 which requires that “The initial medical and nursing assessments are completed within the first 24 hours after the patient’s admission as an inpatient or earlier as indicated by the patient’s condition or hospital policy.”

However, most members of the MMR session are usually unaware of this requirement, and it is the duty of the team leader to explain this standard which requires that to begin correct treatment for a patient as quickly as possible, the initial assessments must be completed as rapidly as possible.

Members of the MMR session must be breifed that the hospital determines the time frame for completing assessments, in particular the medical and nursing assessments depending on a variety of factors including:

  1. the types of patients cared for by the hospital,
  2. the complexity and duration of their care, and
  3. the dynamics of conditions surrounding their care.

Nonetheless, it is important for the team leader to stress that all initial medical and nursing assessments must be completed within 24 hours of admission to the hospital and available for use by all those caring for the patient.

The team leader must also indentify situations when the patient’s condition indicates, that the initial medical and/or nursing assessment are conducted and available earlier and supported by a hospital policy which define that certain other patient groups are assessed sooner than 24 hours.

Such certain other patient groups who are assessed sooner than 24 hours will include:

  1. emergency patients
  2. patients seen in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient

The above certain other patient groups will be assessed within different time frames as follows :

  1. emergency patients are assessed immediately
  2. when the initial medical assessment is conducted in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient, it must be no older than 30 days but (i) if the medical assessment is more than 30 days old, then the medical history must be updated and the physical examination repeated and (ii) if the medical assessment is less than 30 days old but if at the time of admission there are significant changes in the patient’s condition since the assessment was first done, then they are noted in the patient’s medical record at the time of admission to inpatient status.

The team leader may include to explain the rationale why the above 30 days time frame applies when the assessment is completed in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient. Such explanation may include (JCI, 2010 p. 80) “the critical nature of the findings, the complexity of the patient, and the planned care and treatment (for example, the review confirms the clarity of the diagnosis and any planned procedures or treatments; the presence of radiographs needed in surgery; any change[s] in the patient’s condition, such as control of blood sugar; and identifies any critical lab tests that may need repeating)”, findings by any qualified individual (medical, nursing, and other individuals and services responsible for patient care) who usually will update and/or re-examine this patient group.

Reader can relate this post to the previous post Assessments within 24 hours (this link will open in a new tab of your current browser window) on the JCI Standard AOP.1.5 which states that “Assessment findings are documented in the patient’s record and readily available to those responsible for the patient’s care.”

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