Category Archives: JCI Standards AOP

Surgical information that require documentation in medical records

Posted on by
1

Now I have completed relevant posts on surgical information that belong to the contents of a typical medical record for a patient who had undergone surgery, I like to summarise the Joint Commission International (JCI) standards and requirements that directly affect surgical information which requires documentation in medical records.

At this juncture, I like to reiterate that I am not advocating JCI’s program for hospital accreditation. I have used their standards as a benchmark to make medical records documentation to a better quality and as evidence of proper care.

I have also run up each post with a background to a specific surgical information in the medical record, so that Health Information Management (HIM) / Medical Records (MR) practitioners are not just managing medical records literally and not understanding and knowing the background of pieces of scientific information which accumulates inside the medical records.

In my opinion, knowing the nature and structure of surgical information in a medical record make a better HIM/MR practitioner, who is able to stand up for and argue for the quality of medical and surgical information in medical records.

Someone has to fight for the quality of medical records, and who is less important and relevant than HIM/MR practitioners who are the rightful custodians of medical records. I think it is not HIM/MR management practice is not only about medical records assembly, filing, coding, preparing statistical reports and medico-legal processing, etc., but accruing knowledge on HIM/MR management with regards to “WHAT is this thing we are managing”, “WHY are we keeping this?”, and ”HOW can we contribute to the quality of documentation?”.

From the post Medical information that require documentation in medical records (this link will redirect you to a new tab of your current browser window), I had presented all the necessary requirements about of medical information that require documentation in a medical records which explicitly stated what is to be documented in a medical record and also standards which implicitly indicated  medical information that require documentation in a medical record.

For surgical information that require documentation in a medical record, I have a count of twelve (12) standards – or also as one can say “requirements”, which explicitly state what is to be documented in a medical record. There are no standards that indicate implicitly any necessity for surgical information to be documented in a medical record.

I have tabulated all the 12 requirements in some charts. But before displaying the charts on the 12 requirements, allow me to summarise the perioperative period for a patient scheduled for surgery in the pictorial below. I think this chart below is relevant to understanding the 12 requirements (a larger view of this chart is displayed in a new tab of your current browser window by clicking on this chart).

And now, the charts below (a larger view of each chart is displayed in a new tab of your current window, by clicking on each chart) show the 12 requirements for surgical information.

Slide1SI
I believe, a HIM) / MR practitioner working in a hospital must be knowledgeable enough of the surgical information contents in the medical records in his or her custody and to contribute greatly to their quality. The medical records must contain all of the surgical information as I spoken of above, recorded in them. This condition is regardless of the type of hospital they work at, irrespective if his or her hospital had acquired JCI accreditation status or one that is seeking JCI accreditation status or it is one that is not seeking JCI accreditation status at all.

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

Collaboration, and the holistic care of the patient

Posted on by
2

The Joint Commission International (JCI) has a set of two criteria regarding collaboration between members of an interdisciplinary health care team in a hospital which uses an interdisciplinary approach seeking or already with JCI hospital accreditation status. The first criterion is by meeting compliance with JCI Standard AOP.4  that requires “Medical, nursing, and other individuals and services responsible for patient care collaborate to analyze and to integrate patient assessments.” The second criterion is by meeting the JCI Standard AOP.4.1 when “The most urgent or important care needs are identified.”

A patient may undergo many kinds of assessments outside the hospital which include the community and third-party payers (both public and private reimbursement organisations, for example an insurance company or for example in Malaysia – SOCSO, the abbreviation for Social Security Organisation, and it is commonly known in the Malay term as PERKESO or Pertubuhan Keselamatan Sosial, a social security organisation which provides social security protection by social insurance including medical and cash benefits, provision of artificial aids and rehabilitation to Malaysian employees to reduce the sufferings and to provide financial guarantees and protection to the family), and inside the hospital by many different departments and services which includes hospital staff such as a doctor, a nurse, a dietitian, a social worker, and a physiotherapist in the care delivery of a patient that these health care providers must meet.

A collaborative process takes place during an initial assessment. This is a process during which patients are screened by nurses to identify those at nutritional risk, and is one kind of assessment used to plan, to deliver, and to monitor nutrition therapy.These patients are referred to a nutritionist for further assessment. When it is determined that a patient is at nutrition risk, a plan for nutrition therapy is carried out. The patient’s progress is monitored and recorded in his or her medical record. Doctors, nurses, the dietetics service, and, when appropriate, the patient’s family are seen collaborating to plan and to provide that nutrition therapy.

Collaboration to plan and to provide nutrition therapy as in the above example, clearly benefits such a patient most on the basis of recommendations by an interdisciplinary health care team by examining another’s viewpoint when the staff responsible for the patient work together (collaborate) to gather data, plan, implement, evaluate, and gain objectivity from the patient’s medical record. During this process, the most urgent or important care needs are identified, for example the need for nutrition therapy for a patient at nutrition risk. When patient assessment data and information are analysed and integrated, the JCI Standard AOP.4, ME 1 requirement is clearly met.

From such kinds of interdepartmental collaboration, the patient’s needs have been identified, the order of their importance established, and care decisions made. Integration of findings at this point will facilitate the coordination of care provision that helps ensure an efficient care processes, more effective use of human and other resources, the likelihood a beneficial (cost-effective) outcome and enhances quality and the holistic care of the patient.

The team approach satisfies the JCI Standard AOP.4, ME 2 requirement which requires “those responsible for the patient’s care participate in the process”. This is when health care providers from all the relevant disciplines are involved in a multidisciplinary evaluation which mandates active involvement of all the care providers in the evaluation of quality care. This participatory process of evaluation facilitates options and services for meeting the patient’s health and helps promote a continuum of care for the patient, from the preadmission phase to discharge planning and follow-up care.

The goal of the interdisciplinary health team during acute hospitalisation and rehabilitation is to restore function, thus maximising the level of the patient’s independence.

At the same time, health care providers are challenged to work in greater collaboration to decrease the client’s length of stay in the hospital, increase satisfaction with the services, and prevent complications.

It can be said that the majority of clinical transactions in hospital settings are routine and straightforward enough to warrant no special attention or modification to their management (Kingsley & Sam, 2009). Being faced with a complicated clinical transaction, and having to decide whether and how to intervene, require a methodical approach. An example of a complicated a clinical transaction maybe a patient presenting with physical illness may precipitate the relapse of psychiatric illnesses such as manic-depressive psychosis or schizophrenia.

This kind of complicated clinical transactions requires a dynamic and systematic collaborative approach in providing and coordinating for example, using tools and techniques to better integrate and to coordinate care for their patients through formal treatment team meetings, team-delivered care, multidepartmental patient conferences and clinical rounds, combined care planning forms, integrated patient record, and case managers.

The patient, families of the patient and others who make decisions on the patient’s behalf are not neglected in the care process but are duly informed of the planned care and treatment and participate in the decisions about the priority needs to be met.

For patients and families to participate in care decisions, they need basic information about the medical conditions found during assessment, including any confirmed diagnosis when appropriate, and on the proposed care and treatment. Although some patients may not wish to personally know a confirmed diagnosis or to participate in the decisions regarding their care, they are given the opportunity and can choose to participate through a family member, friend, or a surrogate decision maker.

Collaboration includes encouragement  to participate in family support groups through a family member, friend, or a surrogate decision maker in problem-solving activities in the decision process involving treatment and aftercare plans to promote continuity of care when it is needed. Such collaborative encouragement meets the requirements of ME 2 and ME3 of the JCI Standard AOP.4.1.

These actions to promote collaboration with the patient and his or her family and others when the patient’s needs are prioritised based on assessment results,  will comply with the requirement of the JCI Standard AOP.4.1, ME 1 and when the patient and family members are fully aware of the treatment process and outcomes, then the requirements of both ME 2 and ME3 of the JCI Standard AOP.4.1 are also clearly met.

A Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital with JCI accreditation status or one that is seeking accreditation status, must know how the patient’s medical record facilitates and reflects the integration and coordination of care when each practitioner records observations and treatments in the patient’s medical record. Also, when any results or conclusions from collaborative patient care team meetings or similar patient discussions are written in the patient’s medical record.

With this post, I believe I have covered postings about medical documentation found in a typical medical record and their relationship to the relevant JCI standards.

In my next post about medical documentation found in a typical medical record, I shall summarise and tabulate the  relevant JCI standards and their respective requirements, and move on to posting on the remainder of the surgical documentation found in a typical medical record, and their relationship to the relevant JCI standards.

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

Kingsley, N & Sam, S 2009, Problems with patients, Cambridge University Press, NY, USA

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Initial medical assessments results in an initial diagnosis

Posted on by
Reply

From the earlier post Medical documentation in medical records of initial medical and nursing assessments, I wrote about the initial assessment which includes :

  • an evaluation of the patient’s medical status through a physical examination and health history
  • the psychological assessment determines the patient’s emotional status (for example, if he or she is depressed, fearful, or belligerent and may harm him- or herself or others)
  • gathering social information on a patient’s social, cultural, family, and economic contexts are important factors that can influence his or her response to illness and treatment but is not intended to “classify” patients
  • inputs from patient’s families  providing helpful clues in these areas of assessment and in understanding the patient’s wishes and preferences in the assessment process
  • economic factors as part of the social assessment or assessed separately when the patient and his or her family will be responsible for the cost of all or a portion of the care while an inpatient or following discharge

You would have also read from that post, how many different qualified individuals may be involved in the assessment of a patient. The most important factors are that the assessments are complete and available to those caring for the patient.

Image credit : http://kcougs.wordpress.com

When the initial assessments are completed and available, the doctor forms and initial diagnosis. The initial diagnosis ia an important part of the medical documentation in a medical record.

For quality assurance purposes, and for benefit of a Health Information Management (HIM) / Medical Records (MR) practitioners working in a hosptial that is actively undergoing an accreditation program for quality assurance and if your hospital is adopting the Joint Commission International (JCI)  acrreditation program, do take note that the initial diagnosis is an important medical documentation by a doctor in a medical record and must always be present in a medical record in order to comply with the Joint Commission International (JCI) Standard AOP.1.2, ME 4 which states that “The initial assessment(s) results in an initial diagnosis”.

For your information the JCI Standard AOP.1.2 states that “Each patient’s initial assessment(s) includes an evaluation of physical, psychological, social, and economic factors, including a physical examination and health history.”

Also ensure that all your inpatient and outpatient medical records :

  • contain documentation about an initial assessment(s) that includes a health history and physical examination consistent with the requirements defined in hospital policy,  thus complying with the JCI Standard AOP.1.2, ME 1
  • contain documentation about that each patient had received an initial psychological assessment as indicated by his or her needs, which will then comply with the JCI Standard AOP.1.2, ME 2 ; and
  • contain documentation that shows each patient received an initial social and economic assessment as indicated by his or her needs, which will also then comply with the JCI Standard AOP.1.2, ME 3

In summary, your medical records documentation must comply with the JCI Standard AOP.1.2 and its four (4) requirements, if your hospital hopes to meet this JCI accreditation standard of quality of care.

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

Assessments within 24 hours

Posted on by
Reply

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

Medical documentation in medical records of initial medical and nursing assessments

Posted on by
Reply

In everyday life, you and me conduct many informal assessments. One common assessment is whether you or me is hungry and when will you or me will be able to eat next. Such assessments made each day determine many of our actions and influence our comfort and success for the remainder of the day.

Virtually every health care professional performs assessments to make professional judgments related to patients. Doctors and nurses make assessments on a patient, the patient’s family, or the patient’s community to determine medical and nursing interventions that directly or indirectly influence the health status of a patient.

Pals, the purpose of a doctor or nursing health assessment is to collect subjective data -data that rely on the feelings or opinions of the person experiencing them and which cannot be readily observed by another, and objective data – which are measurable data (also called signs) that can be seen, heard, or felt by someone other than the person experiencing them, to determine a patient’s overall level of functioning in order to make a professional clinical judgment.

Subjective data from the patient’s point of view (also referred to as symptoms) are obtained through interviews with the patient, includes:

  1. data regarding sensations or symptoms (e.g., pain, hunger)
  2. feelings (e.g., happiness, sadness)
  3. perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the patient

Objective data on the other hand, are directly observed by the examiner and those obtained by general observation and by using the four physical examination techniques: inspection, palpation, percussion, and auscultation and typically includes :

  1. physical characteristics (e.g., skin color, posture)
  2. body functions (e.g., heart rate, respiratory rate)
  3. appearance (e.g., dress and hygiene)
  4. behavior (e.g., mood, affect)
  5. measurements (e.g., blood pressure, temperature, height, weight)
  6. results of laboratory testing (e.g., platelet count, x-ray findings)

Doctors also base their initial assessments from the patient’s medical/health record as another source of objective data, which is the document that contains information about what other health care professionals (i.e., nurses, physical therapists, dietitians, social workers) observed about the patient. Doctors can also gather objective data made by observations noted by the family or significant others about the patient.

However, the purpose of a nursing health history and physical examination differs greatly from that of a medical or other type of health care examination (e.g., dietary assessment or examination for physical therapy). A nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the patient. Thus the nurse performs holistic data collection.

In contrast, the doctor performing a medical examination focuses primarily on the patient’s physiologic development status.

As Health Information Management (HIM) / Medical Records (MR) practitioners working at a JCI accredited hospital or a hospital being accredited, you need to know about a quality standard declared by the Joint Commission International (JCI) through the Standard AOP.1.3 which states “The patient’s medical and nursing needs are identified from the initial assessments and recorded in the clinical record.” and its five (5) Measurable Elements (MEs).

The JCI quality standard AOP.1.3 is yet another medical documentation requirement as recorded in your medical records

An initial comprehensive assessment involves a collection of subjective data about a patient’s perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the patient’s overall function) as well as objective data gathered during a step-by-step physical examination.

In a hospital setting, the doctor is responsible for the objective data collection for an initial comprehensive assessment and usually performs a total physical examination when the patient is admitted, while the nurse typically collects the subjective data, especially those related to the patientt’s overall function.

The objective data collection by the doctor identifies the patient’s medical needs from this initial assessment, documented health history, physical exam, and other assessments performed based on the patient’s identified needs as required by the JCI Standard AOP.1.3, ME 1.

The initial assessment by a nurse is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the process: diagnosis, planning, implementation, and evaluation. Although an initial assessment process precedes the other phases in the formal nursing process, nurses are always aware that assessment is ongoing and continuous throughout all the phases of the nursing process.

The nursing care needs of the patient identified by the nurse’s holistic data collection as outlined above, thus complies with the JCI Standard AOP.1.3, ME 2 i.e the nurse’s documented assessment, the medical assessment, and other assessments performed are based on the patient’s needs.

Regardless of who collects the data, a total initial health assessment (subjective and objective data regarding functional health and body systems) is needed when the patient first enters a hospital and periodically thereafter to establish baseline data against which future health status changes can be measured and compared. Frequency of comprehensive assessments depends on the patient’s age, risk factors, health status, health promotion practices, and lifestyle

The identified medical needs and the identified nursing needs of the patient must be documented in the patient’s clinical record as required by the JCI Standard AOP.1.3, ME 3 and ME4 respectively.

To accomplish the requirements of the JCI Standard AOP.1.3 namely ME 1. ME 2, ME 3 and ME4,  a hospital must determine the following requirements incorporated within written  policies and procedures which supports consistent practice in all areas :

  1. the minimum content of the initial medical and nursing and other assessments
  2. the time frame for completion of assessments including completion of the most urgent care needs identified from integrated assessments
  3. the documentation requirements for assessments including the integration of the additional assessments by other health care practitioners, including special assessments

If the above three requirements are met, I strongly believe that a hospital complies with the JCI Standard AOP.1.3, ME 5 which states that “Policies and procedures support consistent practice in all areas”.

Although the medical and nursing assessments are primary to the initiation of care, there may be additional assessments by other health care practitioners, including special assessments and individualised assessments. This is an integration requirement of the third requirement of written  policies and procedures on initial assessments I mentioned above.

Examples are, when a physical therapist performs a musculoskeletal examination, as in the case of a stroke patient, and a dietitian who may take anthropometric measurements in addition to a subjective nutritional assessment.

These assessments must be integrated into the initial assessment and the most urgent care needs identified. This is a time frame requirement of the second requirement of written  policies and procedures on initial assessments.as I also mentioned above.

Once a patient’s medical and nursing needs are identified from the initial assessments and duly recorded in the medical record, I conclude that a hospital then complies by the JCI Standard AOP.1.3

Please take note that the JCI Standard AOP.1.3 does not include the initial medical and nursing assessments of emergency patients.

References:
Janet, W & Jane, HK 2010, Health assessment in nursing, 4th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

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

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA