Category Archives: ASC.5.3

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

Check your medical record for patient monitoring during anaesthesia

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This saturday weekend evening, I finish a post on one of the six (6) standards for Anaesthesia Care found in the Joint Commission International Accreditation Standards For Hospitals, 4th Edition that requires documentation in the medical record. I have two (2) more remaining standards to write about under Anaesthesia Care. This post is about patient monitoring during anaesthesia.

The overall monitoring during anaesthesia is a continuous process (“continuous” meaning, prolonged without any interruption at any time) mandated by accreditation requirements for example, by the Joint Commission International (JCI) Standard ASC.5.3, as one of the JCI standards that guide the quality improvement program in anaesthesia that apply to all general anaesthetics, regional anaesthetics, and monitored anaesthesia care. JCI Standard ASC.5.3  evaluates the quality of care by attention to the process of monitoring of the patient during anaesthesia. Adequate monitoring is a key factor (Ronald & Manuel, 2011) in the prevention of patient injury related to anaesthesia

Monitoring and maintenance of normal physiology during the perioperioperative period of anaesthetised patients is designed to collect data that reflect the patient’s ongoing physiologic conditions and any responses that may result from therapeutic interventions. Monitoring allows the anaesthesiologist to react to adverse physiologic changes or trends before they result in irreversible damage. Monitoring is deemed (Ronald & Manuel, 2011) to serve to further enhance the vigilance of the anaesthesiologist and decrease the role of human error in anaesthetic morbidity and mortality.

Monitoring methods depend on the patient’s preanaesthesia status, anaesthesia choice, and complexity of the surgical or other procedure performed during anaesthesia.

The vigilance of the anaesthesiologist is enhanced by the use of a monitoring equipment such as the anaesthesia workstation (previously recognised as the anaesthesia machine) which has evolved (Ronald & Manuel, 2011) from a simple pneumatic device to a complex integrated computer controlled multicomponent workstation that includes physiologic monitoring systems (electrocardiogram, arterial blood pressure, temperature, pulse oximeter, and inhaled and exhaled concentrations of oxygen, carbon dioxide, anaesthetic gases, and vapors). The anaesthesia workstation provides objective data to the anaesthesiologist’s own subjective observations.

From my experiences, it is commonly viewed that anaesthesia standards are applicable in whatever setting anaesthesia and/or moderate or deep sedation are used because of the (JCI, 2011) common and complex processes of the administration of anaesthesia during which the patient’s protective reflexes needed for ventilatory functions are at risk.

In the prevention of patient injury related to anaesthesia,  JCI Standard ASC.5.3 or in all cases when the use of  (JCI, 2011) anaesthesia, sedation, and surgical interventions are common at settings which include hospital operating theatres, day surgery or day hospital units, dental and other outpatient clinics, emergency services, intensive care areas, or elsewhere must have a hospital policy and standard operating procedures which address the following issues for anaesthetised patients:

  1. the basic anaesthetic monitoring standards adopted for example from Standards for Basic Anaesthetic Monitoring  by the American Society of Anaesthesiologists, that mandate (Ronald & Manuel, 2011) the use of pulse oximetry, capnography, an oxygen analyzer, disconnect alarms, body temperature measurements, and a visual display of an electrocardiogram (ECG) during the intra-operative period in all patients undergoing anaesthesia.
  2. the minimum frequency, for example systemic blood pressure and heart rate must be evaluated every 5 minutes
  3. the choice of intra-operative monitoring during anaesthesia depends on the patient’s medical condition and the complexity of the intra-operative procedure
  4. the type of anaesthesia is uniform for similar patients receiving similar anaesthesia wherever anaesthesia is provided
  5. the patient’s physiological status assessed immediately after recovery from anaesthesia

The JCI Standard ASC.5.3 requires documentation of monitoring of the patient during administration of anaesthesia. An anaesthesia record is required and must be maintained when a patient receives an anaesthetic other than a local anaesthetic to document patient monitoring during administration of anaesthetic agents and other activities related to the surgical episode (intra-operative anesthesia).

Documentation regarding monitoring of the patient during administration of anaesthesia  in the anaesthesia record includes (Michelle & Mary, 2011) the following records:

  1. anaesthetic agents administered, including amount, technique(s) used, effect on patient, and duration
  2. patient’s vital signs (e.g., temperature, pulse, blood pressure) enhanced by the use of a monitoring equipment such as the anaesthesia workstation
  3. other activities related to the surgical episode like any blood loss, transfusions administered, including dosage and duration, IV fluids administered, including dosage and duration
  4. the patient’s physiological status immediately after recovery from anaesthesia

If your hospital shows the (a) existence of a policy and procedures that address the standards required for the (i) minimum frequency of monitoring, (ii) type of monitoring,  (iii) process of monitoring of the physiological status during the administration of anaesthesia and immediately after recovery from anaesthesia is uniform for similar patients receiving similar anesthesia wherever anesthesia is provided, and when (b) all the results of monitoring during anaesthesia are written into the patient’s anaesthesia record, I think it is safe to conclude that your hospital fully meets the JCI Standard ASC.5.3 and its three (3) Measurable Elements requirements for documentation of monitoring of the patient during administration of anaesthesia.

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

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 Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA