Category Archives: JCI Standards AOP

Assessments before Anesthesia or Surgery

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Preoperative assessment is the assessment done before surgery, i.e the phase when a patient is prepared for surgery in the time span that includes preparation for, the process of, and recovery from surgery.

Gathering of prompt and accurate initial medical assessment information about the patient before surgery helps to ensure a successful outcome for the patient.

This information gathering is largely a nursing function, with assessments also done by the surgeon, the anesthesiologist or a registered nurse anesthetist (RNA).

What you need to know as a Health Information Management / Medical Records practitioner is that patients for whom surgery is planned have a medical assessment performed before the anesthesia or surgery as required by the JCI Standard AOP.1.5.1, ME 1, and this medical assessment of surgical patients is documented in the medical record before surgery as required by the JCI Standard AOP.1.5.1, ME 2.

Maybe it is good to know what kind of data is gathered in an initial medical assessment before anesthesia or surgical treatment.as required by the the JCI Standard AOP.1.5.1 and what goes into the medical record you keep.

Assessment before aneasthesia or surgery includes :

  • observations by the nurse – any unusual reactions or observations recorded in the patient’s medical record and reported to the charge nurse or surgeon at once
  • vital signs the morning of surgery and any significant deviation from normal recorded and reported
  • a general systems review, noting in particular any new cardiopulmonary developments that place the patient at highrisk during surgery
  • a complete physical examination, including laboratory tests and their results recorded in the patient’s record and, if abnormal, reported to the surgeon or their representative – for nonemergency surgery, laboratory tests done about a week before the procedure.

Routine, preoperative laboratory tests often include :

  • a chest x-ray
  • complete blood count (CBC)
  • urinalysis (UA)

Other laboratory tests and examinations will include:

  • a metabolic panel
  • a toxicology screen, if there is a possibility of alcohol or drug abuse.
  • a pregnancy test may be done, to determine what, if any, medication can be used. are performed as needed
  • an electrocardiogram is usually obtained for all patients older than 40 years
  • blood is drawn for a type and cross match if any possibility exists that a blood transfusion will be needed during surgery
  • patient’s weight is documented in kilograms, because dosages of medications, including anesthetics, are usually calculated on the basis of the patient’s kilogram weight
  • a visit from the anesthesiologist or nurse anesthetist (RNA) before surgery enables a patient to ask questions that may be troubling him or her and allows the anesthesiologist or RNA to assess the patient based on the assessment findings listed above – “patient management by anesthesiologists is generally highly standardized and includes some of the most robust safety engineering found in health care”, (ACMQ 2010).

As I end this post, I wish to record that this posting brings back memories of my multifaceted experiences, skills acquired and the joy when I worked as a medical assistant (an equivalent to a male nurse) in my start-off, one singular career phase of my life.

References:
American College of Medical Quality, 2010, Medical quality management : theory and practice, 2nd edn, Jones and Bartlett Publishers, Sudbury, MA, USA

Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

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

Pain assessment findings documentation in medical records

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I think as Health Information Management(HIM)/Medical Records(MR) practioners, it is never objectionable to know the background on pain assessment documentation found among the contents of a medical record.

A background I would consider knowing about is what is pain all about, how pain is managed including the assessment process, the tools used to measure pain, and pain assessment documentation.

Pain which is now considered to be the fifth vital sign, is also assessed whenever the other four vital signs namely temperature, pulse, respiration, and blood pressure are measured.  Patients are asked on a regular basis if they are experiencing pain. The evaluation of pain, along with other vital signs, alerts the nurse and other healthcare providers to the necessity of addressing the patient’s pain. Relief of pain helps the patient to be more comfortable and to recover more quickly.

What is pain then?

Because pain is a subjective symptom which only a patient can describe it, pain is difficult to define. However we know as humans that pain is the body’s signal of distress, and is very difficult to ignore. Most of us try many remedies to relieve pain, often without success. Ultimately, it is one of the most common reasons that most of us seek healthcare.

Here I list some notable definitions of pain, a universal human experience:

  • ‘Pain is whatever the experiencing person says it is, existing whenever he says it does’, stated by pain theorist, Margo McCaffery
  • The Agency for Healthcare Research and Quality (AHRQ) in its clinical practice guidelines for acute pain management states that the ‘client’s self-report is the single best indicator of pain’
  • One definition of pain in a medical dictionary includes ‘a feeling of distress, suffering, or agony, caused by stimulation of specialized nerve endings’
  • The International Association for the Study of Pain defines pain as ‘An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage’

Pain is classified in several ways. Duration and etiology are often classified together to differentiate acute pain, chronic nonmalignant pain, and cancer pain. Pain location classifications include cutaneous pain, visceral pain, and deep somatic pain, radiating, and referred. Phantom pain can be perceived in nerves left by a missing, amputated, or paralyzed body part. Other types of pain are neuropathic pain and intractable pain.

I am sure you would have noticed these terms used in the medical record in the course of reading the medical record, example for ICD-10 coding purposes.

The experience of pain is quite complex and the multidimensional complexity of pain can be described in seven dimensions: physical, sensory, behavioural, sociocultural, cognitive, affective, and spiritual.

Pain is managed with the use of pharmacological (oral medication, Intravenous Medication (IM), Intravenous Venous (IV) medication, IV continuous medication) and non- pharmacological interventions (which may include warm and cold compresses, heat and cold applications at a Rehabilitation Department, position change and relaxation exercises to control the patient identified pain). Pharmacological and non-pharmacological interventions extend beyond pain relief, encompassing the patient’s quality of life, and ability to function or work productively. Pain relief after surgery is improved with the combined use of different classes of analgesic. There may also be an associated reduction of the dose of each analgesic drug and the intensity of any side effects.

Patients are assessed appropriate to patient’s age:

  • within one hour on admission to the ward, including Day Surgery and Endoscopy
  • upon inter-ward transfer
  • at the beginning of each outpatient visit to the departments such as the AE, Rehabilitation Department, Oncology Centre
  • following a surgical procedure or treatment
  • when the patient complains of pain
  • before and after administration of medication and / or treatment.
  • at time of discharge

Allow me now to go on and discuss the pain assessment tools and findings documentation found in medical records.

Pain screening is very important in developing a comprehensive plan of care for the client. Therefore, it is essential to assess for pain at the initial assessment. Pain intensity measurement tools such as a 1 to 10 Likert scale may be used.

There are many pain assessment scales; for example, Visual Analog Scale (VAS), Numeric Pain Intensity Scale (NPI), Simple Descriptive Pain Intensity Scale, Graphic Rating Scale, Verbal Rating Scale, and Faces Pain Scales (FPS, FPS-R), and the more common Wong-Baker Faces Pain Scale (a picture scale).  You can find out more on some of these scales from http://www.partnersagainstpain.com/measuring-pain/assessment-tool.aspx (this link will open in a new tab of your current window).

While there are no laws in Malaysia that  necessitates pain assessment and documentation, some states in the United States have passed laws necessitating the adoption of an assessment tool and documenting pain assessment in patient charts along with temperature, pulse, heart rate, and blood pressure.

So what is important for you as a HIM/MR practitioner is that pain assessment findings and treatment are documented in the patient’s record and readily available to those responsible for the patient’s care.

However if you working in a hospital in the process of accreditation,  for example using the Joint Commission International(JCI) quality standards , then it is important to know the JCI requirements to improve the management of pain which are as follows:

  • patients have the right to appropriate assessment and management of pain
  • on-going pain assessment should include the nature and intensity of pain, thus the use of pain scales to help clients determine their level of pain
  • responses to evaluation of pain should be recorded in a manner that promotes regular reassessment and follow-up
  • staff must be oriented and competent in assessment and management of pain
  • policies and procedures supporting ordering of pain medications must be in place
  • patients and families require education about effective pain management.
  • discharge planning should address the patient’s needs for management of pain

The JCI requirement that specifically requires that the medical record contain documentation on pain assessment is non-other than the JCI Standard AOP.1.7 which states that ‘All inpatients and outpatients are screened for pain and assessed when pain is present.’

The intent of JCI Standard AOP.1.7 is to ensure that a screening procedure is used to identify patients with pain during the initial assessment and during any reassessments. When pain is identified and when the patient is treated in the hospital, then this assessment is recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the hospital and the patient’s needs. JCI Standard AOP.1.7 Measurable Element (ME) 3 then measures if the medical records have evidence that ‘the assessment is recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the hospital and the patient’s needs.’

References:
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

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 Edition, USA, JCI

PartnersAgainstPain.com website