Category Archives: ASC.3

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

Pre-sedation assessment documentation

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Image credit: patientsafetyauthority.org/

My purpose of including this post about pre-sedation assessment is because it warrants a provision to check for compliance against the Joint Commission International (JCI) Standard ASC.3 which requires documentation of a pre-sedation assessment and monitoring of the patient during administration of moderate or deep sedation or anesthesia using the Medical Records Review Tool (MMRT) form, similar to the situation  when the JCI Standard AOP.1.4. which also examines the documentation in a medical record during a Medical Records Review (MMR) session.

Sedation (JCI, 2011 p.245) at three (3) levels of sedation – minimal sedation (patient can respond to command), moderate sedation (depressed level of consciousness; patient can breathe without assistance, respond to pain, and follow some commands. protective reflexes are maintained),  and deep sedation (patient cannot be easily aroused, but can respond after repeated stimulation. respiration may need to be supported), is “the administration of medication to an individual, in any setting, for any purpose, by any route to induce a partial or total loss of sensation for the purpose of conducting an operative or other procedure.” as defined in the Glossary  of the JCI Hospital Acceditation Standards For Hospitals, 4th Edition Manual.

So what needs to be checked for compliance against this JCI Standard ASC.3, which states that “Policies and procedures guide the care of patients undergoing moderate and deep sedation.” in the medical record of a patient due for the purpose of conducting an operative or other procedure on the patient.” and specifically its Measurable Element (ME) 3 which requires that “There is a pre-sedation assessment performed that is consistent with organization policy to evaluate risk and appropriateness of the sedation for the patient.?

Such aforesaid policies and procedures of a hospital must define the scope and content of a pre-sedation assessment to guide the care of patients undergoing moderate and deep sedation. A responsible qualified individual competent in (a) techniques of various modes of sedation, (b) appropriate monitoring, (c) response to complications, (d) use of reversal agents, and (e) at least basic life support, conducts a pre-sedation assessment of the patient to ensure the planned sedation and determine the appropriate level of sedation for the patient that is consistent with hospital policy to evaluate risk and appropriateness of the sedation for the patient. Pre-sedation assessment is important in particular for moderate and deep sedation levels because the degrees of sedation occur on a continuum, and a patient may progress from one degree to another, based on the medications administered, route, and dosages.

A pre-sedation assessment will include the following to ensure a patient’s ability to maintain protective reflexes; an independent, continuous patent airway; and the capability to respond to physical stimulation or verbal commands :

a) how planning will occur as I covered in the post Anaesthesia plan in the patient’s medical record (this link will open in a new tab of your current browser window), including the identification of differences between adult and paediatric populations or other special considerations for patients with significant underlying medical conditions (e.g., extremes of age; severe cardiac, pulmonary, hepatic, or renal disease; pregnancy; drug or alcohol abuse, uncooperative patients, morbid obesity, potentially difficult airway, sleep apnea);

b) documentation required for the care team to work and to communicate effectively;

c) informed consent must be obtained for all non-emergency procedures and special consent  for example when informed consent is obtained moments before a patient will undergo a major, potentially life-threatening or disfiguring procedure;

d) frequency and type of patient-monitoring requirements;

e) special qualifications or skills of staff involved in sedation process as I posted under the post Anesthesia care must be given by a qualified individual (this link will open in a new tab of your current browser window); and

f ) availability and use of specialised equipment.

Recommendations on Pre-Anaesthetic Assessment , one of the six (6) Clinical Practice Guidelines (CPGs) of the Malaysian Society of Anaesthesiologists (MSA) recommends that  “A written summary of the pre-anaesthetic assessment, orders or arrangements should be explicitly and legibly documented in the patient’s anaesthetic record”.

Likewise, another MSA CPG – Recommendations for Standards of Monitoring During Anaesthesia and Recovery, makes special mention on sedation and recommends that (i) A patient who is to be given any form of sedation for a procedure should be assessed by a qualified medical practitioner and his medical status noted.”, and (ii) “A written record of the time and dosages of the drugs used must be kept as part of the patients records. This record must also note the monitored values of the patients vital signs( i.e. blood pressure, pulse rate. respiration, and oxygen saturation) .”

Examples of presedation assessment forms for adults and paediatrics with links from this post are as follows :

Adult Sedation Pre-Sedation Assessment Form example (this link will open in a new tab of your current browser window)

Paediatric Sedation Pre-Sedation Assessment Form example (this link will open in a new tab of your current browser window)

It is also possible to find pre-sedation assessment recorded in the anaesthesia record.

Before I close the discussion on pre-sedation assessment in this post, I like to recommend the following based on my experiences:

  1. a special, separate special pre-sedation medication form or the pre-sedation medication form printed on the reverse side of the anaesthetic record form or elements of the pre-sedation assessment included as part of the anaesthetic record form;
  2. team members of a MMR session must be briefed about (a) the pre-sedation assessment process compliance check for JCI Standard ASC.3 in the MMRT form, and (b) about the presence of a pre-sedation assessment form in a medical record for patients undergone pre-sedation assessment and monitoring during the administration of moderate or deep sedation;
  3. a medical record is just not complete if there is no pre-sedation assessment form in a medical record for patients undergone pre-sedation assessment and monitoring during the administration of moderate or deep sedation, so Health Information Management (HIM) / Medical Records (MR) practitioners must ensure a medical record for such patients is completed with a pre-sedation assessment record;
  4. reporting the presence of a  pre-sedation assessment form in a medical record for patients undergone pre-sedation assessment and monitoring during the administration of moderate or deep sedation is not enough just to satisfy the completion of the process of a MMR session but I believe it is beyond just checking for completeness of the medical record and merely to complete the  MMRT form;
  5. team members of a MMR session must be briefed not only to check for a pre-sedation assessment form in a medical record but also its completeness and team members must notify the MMR session team leader of any incompleteness found; and
  6. the team leader of a MMR session must record such observations of incompleteness found in the pre-sedation assessment form so as to make the MMR session report as value added as possible and to improve the quality improvement activities of the Anaesthesiology Department of the hospital.

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

Children’s Hospital Central California, 2013, Paediatric Sedation Pre-Sedation Assessment Form example, viewed 5 January 2013 < http://www.chccsedation.org/downloads/PreProceduralSP.pdf >

Darthmouth-Hitchcock Medical Centre, Adult Sedation Pre-Sedation Assessment Form example, viewed 5 January 2013 < http://www.dhmcsedation.com/as/downloads/PreAssessmentExample.pdf  >

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

Malaysian Society of Anaesthesiologists (MSA), 2013, Recommendations on Pre-Anaesthetic Assessment, viewed 5 January 2013 < http://www.acadmed.org.my/view_file.cfm?fileid=222 >

Malaysian Society of Anaesthesiologists (MSA), 2013, Recommendations for Standards of Monitoring During Anaesthesia and Recovery, viewed 5 January 2013 < http://www.acadmed.org.my/view_file.cfm?fileid=180 >

Malaysian Society of Anaesthesiologists (MSA), 2013, Recommendations On Pre-Anaesthetic Assessment, viewed 5 January 2013 < http://www.acadmed.org.my/view_file.cfm?fileid=222 >

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Ronald, DM & Manuel, CP Jr 2011, Basics Of Anesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA