Category Archives: JCI Standards ASC

Documentation by the surgeon prior to surgery

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Surgery also often called an “operation”, is an invasive process because an incision is made into the body to repair or remove or replace a part of body tissues or organs as the best treatment for his or her disorder.

As surgery always carries a high level of risk, the surgeon will assess each patient and weigh the surgical risk against the need for surgery.

In some cases, surgery must be done despite the high level of risk due to the presence of risk factors, for example the common instance of  patients presenting for surgery with a pre-existing physical disorder risk factor from diabetes mellitus, with slowed healing, increased incidence of infections, insulin imbalances, inability to regulate blood sugar levels.

When a person is brought in by ambulance and must receive immediate surgery, this emergency patient needs emergency surgery. The assessment process for an emergency patient is carried out in a shortened time frame and the surgery performed immediately to save the patient’s life. Examples are ectopic pregnancy with threat of rupture, severe internal hemorrhage, ruptured appendix, and angioplasty after a heart attack.

So in most normal circumstances, patients for which surgery is planned have a medical assessment and all required tests performed before the surgery. Assessment(s) provide information necessary to :

  1. select the appropriate procedure and the optimal time identified from sequencing the assessments in the clinical care path on a timeline for the patient
  2. perform procedures safely
  3. interpret findings of patient monitoring

The selection of an appropriate invasive procedure considers information from the following sources used to develop and to support the planned invasive procedure by the responsible surgeon before the procedure is performed :

  1. the initial medical and nursing assessment(s) on the patient’s history and physical status
  2. available results that have been reported within a time frame to meet the patient needs (in this case the impending surgery) for all required tests, such as electrocardiogram (ECG), ordered laboratory tests, radiology and diagnostic imaging study

The surgical care planned for the patient is documented in the patient’s medical record, more so if the hospital is seeking or plans to continue maintaining accreditation status  dictated by standards from a hospital quality assurance agency like that of the Joint Commission International (JCI). The JCI standard on documentation by the surgeon prior to surgery is the  Standard ASC.7, which states that “Each patient’s surgical care is planned and documented based on the results of the assessment”, requires the surgeon to document the following prior to performing surgery :

  1. procedure selected
  2. a preoperative diagnosis in the Preoperative Note which is a progress note documented by the surgeon prior to surgery, which summarizes the patient’s condition – the name of the surgical procedure alone does not constitute a diagnosis (JCI 2011)

However I think documentation on the surgical care plan should also incorporate the following although they are not mentioned to meet JCI Standard ASC.7 :

  1. emotional support provided to the patient and the family, especially to the patient who faces surgery as the patient may compare the previous experience with this one and can be particularly frightened if the patient has had any previous experience with surgery which was difficult or the patient facing surgery for the first time may be apprehensive about pain, about losing consciousness, fearful of cancer or of being disabled or worse still some others maybe afraid they will die
  2. preparation of the patient physically for surgery for example a surgical preparation or “prep” is done by cleaning the skin with an anti-infective agent and may be shaved when an incision is to be made in the skin
  3. that all legal matters, such as signing the surgical consent (informed consent), are carried out
  4. routine preoperative care provided

JCI does not say where in the medical record the surgical care plan should be documented. From my experiences, these are often documented in the progress notes and are authenticated by the responsible surgeon.

In summary, If documentation is completed as above in the medical record of a patient prior to surgery, then the hospital seeking or planning to continue maintaining accrediation status from JCI,   will fully meet  JCI’s Standard ASC.7 and it’s four (4) measurable elements.

References :
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

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

The anaesthesia used and anaesthetic technique are written in the patient record

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The decision-making process necessary for deciding which anaesthesia to use and the anaesthetic technique to select is the responsibility of the anaesthesiologist, the anaesthesia provider (the health professional providing the care) rendering the anaesthetic care planned for the patient related to his or her identified needs.

The anaesthesia care provider has several options deciding which anaesthetic technique (Ronald & Manuel 2011) to select available including (1) general anaesthetic – usually induced in adult patients by the intravenous administration of an anaesthetic (propofol, thiopental, or etomidate) that produces rapid onset of unconsciousness, (2) regional anaesthetic – spinal (Spinal anaesthesia is accomplished by injecting local anaesthetic solution into the cerebrospinal fluid (CSF) contained within the subarachnoid (intrathecal) space. or epidural (achieved by injection of local anaesthetic solution into the space that lies within the vertebral canal but outside or superficial to the dural sac) or caudal anaesthesia (represents a special type of epidural anaesthesia in which local anaesthetic solution is injected into the caudal epidural space through a needle introduced through the sacral hiatus) are selected when maintenance of consciousness during surgery is desirable, (3) peripheral nerve block – a technique of anaesthesia for superficial operations on the extremities or (4) monitored anaesthetic care (MAC) – a procedure in which an anaesthetic provider is requested or required to provide anaesthetic services, which include preoperative evaluation, care during the procedure, and management after the procedure.

I shall avoid details of the types of the anaesthesia used and the anaesthetic techniques (I have already given enough extracted text-book explanations in the paragraph above of anaesthetic techniques) used. as I think it is only appropriate for me to highlight in this post what needs to be satisfied by a quality assurance requirement, for example the Joint Commission International (JCI) quality Standard ASC.5.2 which requires that “The anaesthesia used and aesthetic technique are written in the patient record.”

It is clear from the intent of this standard that JCI surveyors must be able to find evidence of  the anaesthesia used and anaesthetic technique written somewhere in the patient’s medical  record during a hospital survey process.  The Health Information Management (HIM) / Medical Records (MR) practitioner’s role should be ensure that he or she can identify the location of this evidence in the medical record and contribute to completeness and quality of the medical record.

Anaesthesia providers qualified to administer anaesthesia like an anaesthesiologist, documents patient monitoring when a patient receives an anaesthetic other than a local and other activities related to the surgical episode. Detailed records of the course of anaesthesia are documented in an anaesthesia record, the piece of evidence of the anaesthesia used and anaesthetic techniques used. Preoperative and postoperative visits, and detailed records of the course of anaesthesia, serve as the best protection for the anaesthesiologist or other authorised anaesthetic provider against medico legal action.

Contents of the anaesthesia record in the usual handwritten anaesthetic record documenting the anaesthesia used and the anaesthetic technique used contain adequate information (Michelle & Mary 2011) and  justify the anaesthesia care as follows:

  1. Preanesthesia medication administered, including time, dosage, and effect on patient
  2. Appraisal of any changes in the patient’s condition (since preanesthesia evaluation)
  3. Anaesthesia agent administered, including amount, technique(s) used, effect on patient, and duration, qualifying for full compliance against ME 1 and ME 2 requirements for JCI Standard ASC.5.2
  4. Patient’s vital signs (e.g., temperature, pulse, blood pressure)
  5. Any blood loss
  6. Transfusions administered, including dosage and duration IV fluids administered, including dosage and duration
  7. Patient’s condition throughout surgery, including pertinent or unusual events during induction of, maintenance of, and emergence from anaesthesia.
  8. Authentication by the individual qualified to administer anaesthesia (e.g., certified registered nurse anaesthetist, anaesthesiologist) and names of anaesthesia assistants identified in the patient’s anesthesia record, would then serve to satisfy full compliance with the ME 3 for Standard ASC.5.2

Here is a part of an anaesthesia record (as below) showing the fields for recording anaesthetic technique and anaesthesia agents used (click on the image for a larger view in a new tab of your current browser window).

Source :Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, pg 163

Do take note that preanaesthesia and postanaesthesia evaluation progress notes are sometimes documented on a special form located on the reverse side of the anaesthesia record.

HIM/MR practitioners should also ensure that the medical record contains all records of previous admissions. This is important when an anaesthesia record of a previous surgery which contains historical information, could yield much useful information for the anaesthesia provider especially in the ease of airway management techniques such as direct laryngoscopy when the physical examination by the anaesthesia provider suggests some risk factors for difficult tracheal intubation. If the historical information from the anaesthesia record of this previous surgery clearly documented uncomplicated direct laryngoscopy for a recent surgery, the anaesthesia provider may then proceed with routine laryngoscopy. .

In conclusion, I think the presence of an completed anaesthetic record in a medical record documenting the anaesthesia used and anaesthetic technique, is sufficient evidence to justify full compliance with JCI Standard ASC.5.2

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

Anaesthesia plan in the patient’s medical record

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A Health Information Management (HIM) / Medical Records (MR) practitioner will find documentation of preoperative activities including each patient’s anaesthesia care which is planned and documented in the patient’s record.

The Joint Commission International (JCI) Standard ASC.5 specifically requires documentation of preoperative activities to include that each patient’s anaesthesia care is planned and documented in the patient’s medical record.

This is true for all patients in the preoperative phase in all hospitals, and not just for hospitals already JCI accredited or seeking JCI or other healthcare quality standards.

After the preoperative evaluation by an anaesthesiologist or another qualified individual as outlined in the post Anesthesia care must be given by a qualified individual (this link will open in a new tab of your current window), anaesthesia care is carefully planned and the anaesthesia plan is created,

The plan includes a list of drug choices and doses in detail, the method of administration, other medications and fluids, monitoring procedures, and anticipated postanesthesia care.

An HIM) / MR practitioner will find documentation of each patient’s anaesthesia care plan as shown in the sample General Anaesthesia Plan below documented in the patient’s medical record.

SAMPLE GENERAL ANAESTHESIA PLAN

Case
A 47-year-old woman with biliary colic and well-controlled asthma requires anaesthesia for laparoscopic cholecystectomy.

Preoperative Phase
Premedication
Midazolam, 1-2 mg IV, to reduce anxiety
Albuterol, two puffs, to prevent bronchospasm

Intraoperative Phase
Vascular access and monitoring
Vascular access: one peripheral IV catheter
Monitors: pulse oximetry, capnography, electrocardiogram, non-invasive blood pressure with standard adult cuff size, temperature
Induction
Propofol, 2 mg/kg IV (may precede with lidocaine, 1.5 mg/kg IV)
Neuromuscular blocking drug to facilitate tracheal intubation (succinylcholine, 1-2 mg/kg IV) or nondepolarizing neuromuscular-blocking drugs (rocuronium, 0.6 mg/kg)
Airway management
Facemask: adult medium size
Direct laryngoscopy: Macintosh 3 blade, 7.0-ID endotracheal tube
Maintenance
Inhaled aesthetic: sevoflurane or desflurane
Opioid-fentanyl: anticipate 2-4 mg/kg IV total during case
Neuromuscular blocking drug titrated to train-of-four monitor (peripheral nerve stimulator) at the ulnar nerve*
Emergence
Antagonize effects of nondepolarizing neuromuscular blocking drug: neostigmine, 70 mg/kg, and glycopyrrolate, 14 mg/kg IV, titrated to train-of-four monitor
Antiemetic: dexamethasone, 4 mg IV, at start of case; ondansetron, 4 mg IV, at end of case
Tracheal extubation: when patient is awake, breathing, and following commands
Possible intraoperative problem and approach
Bronchospasm: increase inspired oxygen and inhaled aesthetic concentrations, decrease surgical stimulation if possible, administer albuterol through endotracheal tube (5-10 puffs), adjust ventilator to maximize expiratory flow

Postoperative Phase
Postoperative pain control: patient-controlled analgesia – hydromorphone, 0.2 mg IV; 6-minute lock-out, no basal rate
Disposition: postanesthesia care unit, then hospital ward*Nondepolarizing neuromuscular blocking drug choices include rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium.

*Nondepolarizing neuromuscular blocking drug choices include rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium.

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

Do take note that sometime the anaesthesia plan may require modification of the plan which may include a specific requirement for an individual patient and thus may have implications for preparing additional equipment in the operating room for example, special equipment that may be kept in a cart dedicated to difficult airway management or in another instance, the patient’s responses to anaesthesia and surgery may also cause the anaesthesia plan to be adjusted.

When each patient’s anaesthesia care is planned and documented in the patient’s record, then you can be sure that medical record fully meets the two requirements of JCI Standard ASC.5

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

Anesthesia care must be given by a qualified individual

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The patient undergoes preoperative nursing assessment (screening), and receives preanesthesia evaluation by an anaesthesiologist to place the patient in the best possible condition for surgery through careful assessment and thorough preparation. Assessment of the patient’s status before surgery establishes baseline data to direct interventions throughout the perioperative phases (the peroperative phase is a phase of the three perioperative phases).

Because anaesthesia carries a high level of risk, a qualified individual must conduct a preanesthesia assessment and preinduction assessment for each patient. For example (Ronald & Manuel, 2011), a patient undergoing coronary artery bypass graft has a significant risk of problems such as death, stroke, or myocardial infarction. A patient undergoing cataract extraction has a low risk of major organ damage.

An anaesthesiologist or certified Registered Nurse Anaesthetist (RNA) are two qualified anaesthesia providers who actively participate in conducting a preanesthesia assessment and preinduction assessment for each patient.

The main role of the anaesthesiologist or RNA is to ensure patient safety relative to the administration of anaesthesia. The anaesthesia provider:

  1. Obtains informed consent for anaesthesia services
  2. Performs a preanesthesia assessment that includes a thorough history, such as complications from previous anaesthesia, and physical examination
  3. Selects anesthetic agents

The patient’s preanesthesia assessment is for the use of postoperative analgesia. The preanesthesia assessment may be carried out some time prior to admission or prior to the surgical procedure or shortly before the surgical procedure, as in emergency and obstetrical patients.

Medical records from previous surgeries are reviewed when appropriate and feasible as part of the preanesthesia examination.

A separate preinduction assessment is performed to re-evaluate patients immediately before the induction of anaesthesia. Assessment evaluates if the patient has coexisting medical problems and if the surgery or anaesthesia care plan needs to be modified because of them. To anticipate the effects of a given medical problem, the anaesthesia provider then focuses on the patient’s physiologic stability from the physiologic effects of the surgery and aesthetic, and readiness of the patient for anaesthesia and occurs immediately prior to the induction of anaesthesia. For example, the anaesthesia provider may change (Ronald & Manuel, 2011) the anaesthetic plan to increase the induction dose of intravenous anaesthetic for a patient with poorly controlled systemic hypertension who is more likely to have an exaggerated hypertensive response to direct laryngoscopy to facilitate tracheal intubation.

When anaesthesia must be provided emergently, the preanesthesia assessment and preinduction assessment may be performed immediately following one another, or simultaneously, but are documented independently. The urgency (Ronald & Manuel, 2011) of a given procedure (e.g., acute appendicitis) may preclude lengthy delay of the surgery for additional testing, without increasing the risk of complications (e.g., appendiceal rupture, peritonitis).

The Joint Commission International (JCI) Standard ASC.4 requires documentation in a medical record for a preanesthesia assessment and a separate preinduction assessment performed to re-evaluate patients immediately before the induction of anaesthesia by “A qualified individual” who “conducts a preanesthesia assessment and preinduction assessment.” for every patient prior to surgery.

An Health Information Management (HIM) / Medical Records (MR) practitioner will find documentation of preoperative activities including preanesthesia assessment using the preoperative checklist and a separate preinduction assessment always entered in the patient’s medical record on the appropriate forms.  This is true for all patients in the preoperative phase in all hospitals, and not just for hospitals already JCI accredited or seeking JCI or other healthcare quality standards.

The preoperative checklist is used to document accurate completion of preoperative activities, including preanesthetic evaluation done (using the preanesthesia evaluation note). This checklist identifies assessments, medications, and other physical preparations that must be completed before the client is anesthetised.

The preanesthesia evaluation note is a progress note (Michelle & Mary, 2011) documented by any individual qualified to administer anaesthesia prior to the induction of anaesthesia. Includes evidence of patient interview to verify past and present medical and drug history and previous anaesthesia experience(s), evaluation of the patient’s physical status, review of the results of relevant diagnostic studies, discussion of preanesthesia medications and choice of anaesthesia to be administered, surgical and/or obstetrical procedure to be performed, and potential anaesthetic problems and risks; sometimes documented on a special form located on the reverse of the anaesthesia record.

An anaesthesia record is required to show preanesthesia medication administered, including time, dosage, and effect on patient, when a patient receives an anaesthetic other than a local anaesthetic.

Preanesthesia (and postanesthesia) evaluation progress notes are sometimes documented on a special form located on the reverse side of the anaesthesia record. This can prove helpful to anaesthesiologists so that no documentation elements are forgotten.

The preanesthesia progress notes and anaesthesia record provide the documentation of the administration of preoperative medications, and evaluation of the patient preoperatively in the medical record. The medical record of a patient must show evidence of a preanesthesia assessment and a separate preinduction assessment that was performed to re-evaluate the patient immediately before the induction of anaesthesia, both of which were conducted by an individual(s) qualified to do so. Such aforementioned evidence meets JCI requirements.

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

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