Category Archives: JCI Standards COP

JCI Standard MCI.4 – accuracy and timeliness of information in the hospital through effective communication

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My intention in bringing this post to a Health Information Management (HIM) / Medical Records (MR) practitioners reader specifically and to all other readers in general, is to understand the dynamics of communication and your role in managing patient-specific information in a hospital setting when the leaders of the hospital agree to an essential condition  whereby effective communication must prevail among and between professional groups; structural units, such as departments; between professional and non-professional groups; between health professionals and management; between health professionals and families; and with outside organisations.

In making this agreement for effective communication throughout the hospital setting, I agree the stipulations that this issue is primarily a leadership function of the hospital’s leaders. This agreement is stipulated in the Joint Commission International (JCI) Standard MCI.4 which states that “Communication is effective throughout the organization”, especially so if you are practising in a hospital accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

The reader as a leader of a structural unit setting and relevant service needs to be aware of the following conditions in this agreement for effective communication:

  1. for patient care to appear seamless, processes must be in place for communicating relevant information in an accurate and timely manner throughout one’s structural unit, such as the HIM / MR department and between other structural units in the hospital; this is to ensure that the processes are designed and implemented to support continuity and coordination of care as patients move through the hospital from admission to discharge or transfer, several departments and services and many different health care practitioners may be involved in providing care; for example from emergency services to inpatient admission
  2. the hospital defines the patient-specific information, example patient’s weight and other physiological information available from the medical record, required for an effective review process and is facilitated by a record (profile) i.e via medication administration records (MAR) or medication list, also to be found within a medical record for all medication administered to a patient except emergency medications and those administered as part of a procedure; the medical record folder is updated after a review of a patient receiving medications, example the folder is tagged with an alert sticker for allergies or sensitivity; this review also facilitates the medication reconciliation process across the continuum of care and the process continues upon discharge and transfer of the patient, and the complete list of patient medications is shared with the next provider of patient care
  3. effective communication occurs in the hospital among the hospital’s programs ranging from the emergency services, inpatient admission, diagnostic services and treatment services, surgical and non-surgical treatment services and outpatient care programs for seamless care
  4. since patients frequently require follow-up care to meet on-going health needs or to achieve their health goals, there is a plan by the hospital’s leaders with the leaders of other health care organisations in its community for effective communication to occur between the leaders of these other health care organisations in its community during referrals; the plan establishes contact with known resources i.e. the patient’s home community and identified specific individuals and agencies that are most associated with the hospital’s services and patient population in order that they help support continuing health promotion and disease prevention education
  5. there are policies and procedures developed to support and to promote patient and family participation in care processes to ensure that continuity and coordination are evident to the patient; effective communication thus occurs with patients and families in these circumstances:
    1. patients and families are involved in care decisions by effective communication thus occurs with patients and families when (i) they understand how and when they will be told of planned care and treatment(s), (ii) understand their right to participate in care decisions to the extent they wish and learn about how to participate in care decisions
    2. inpatients and outpatients who leave against medical advice when patients, or those making decisions on their behalf, may decide not to proceed with the planned care or treatment or to continue care or treatment after it has been initiated guided by a process for the management and follow-up of such cases
    3. effective communication thus occurs with patients and families when those who provide education encourage patients and their families to ask questions and to speak up as active participants
    4. effective communication occurs with patients and families when indicated, planning for referral and/or discharge begins early in the care process ie. soon after admission as inpatients and, when appropriate, includes the family
    5. effective communication occurs with patients and families when patients are reassessed to plan for continued treatment or discharge
    6. effective communication occurs with patients and families such that symptoms and complications are prevented to the extent reasonably possible during the care of the dying patient
  6. and finally. the reader as a leader must not only set the parameters of effective communication but also serve as role models with effective communication of the hospital’s mission and appropriate policies, plans, and goals to all staff.

I acknowledge the role of effective communication and its pervasiveness in creating, gathering and sharing health information in meeting challenges and improving health care outcomes. In this post, I think I have achieved to address some pertinent issues relevant to effective communication when implementing the requirements of the JCI Standard MCI.4 specifically and also delving into the issues of effective communication in general.

References:

  1. Dale, EB & Daena, JG (eds.) 2009, Communicating to manage health and illness, Routledge, London, UK
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
  4. Sheila, P & Sandra, H (eds.) 2007, Health communication Theory and practice, Open University Press, McGraw-Hill Education, England, UK

Nutrition therapy and the medical record

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Patients are screened for nutritional risk as part of the initial assessment with the application of screening criteria to gather information on nutritional status or functional status – often done by nurses, which must also be completed routinely within 24 hours of admission to the hospital or at an earlier time period.

I had covered at length on this requirement as you can follow from the posts (each of the following links will open in a separate new tab of your current browser window) Hospital screening criteria data to identify patients with nutritional or functional needs and 6 steps in documenting hospital screening to identity patients with nutritional or functional needs.

A patient identified with nutritional or functional needs i.e. at nutrition risk, is referred to a nutritionist for further assessment and a collaborate plan for nutrition therapy is carried out by doctors, nurses, and the dietetics service, and when appropriate with the help of the patient’s family. The nutritionist monitors at intervals the patient’s progress from the nutrition therapy, the nutritionist’s reassessment throughout this special care process is part of all reassessment by all the patient’s health care practitioners as the key to understanding whether care decisions are appropriate and effective, and records the progress in the patient’s record.

So what is nutrition therapy?

A patient is after a burn or surgery. Another patient is with a high fever, or suffering from acute diarrhoea. Yet another patient is with diabetes mellitus, a disorder throughout life. One other patient is suffering an acute illness with coronary or vascular disorders.

Nutrition is a vital component of therapy for the above listed disorders. According to (eds. Catherine, Benjamin, Robert, Katherine, & Thomas 2014, p. 1162), “use of the term therapy recognizes the role of nutrition in affecting patient outcome and acknowledges the demonstrable risks and benefits to nutrition intervention in both the short term and the long term.”

So, nutrition therapy is required with a high protein intake to rebuild, repair and heal body tissues after a burn or surgery. Nutrition therapy is provided when a patient needs fluids and electrolytes to replace what is being lost due to haemorrhaging, vomiting, and perspiring profusely. Because most serum glucose depends on dietary intake, nutrition therapy is a vital component in the prevention and management of diabetes mellitus which necessitates a special diet plan. Nutrition therapy  is again necessary with a special diet limiting or modifying the fat and sodium intake for a patient with coronary or vascular disorders.

Thus, Health Information Management (HIM) / Medical Records (MR) practitioners will find within medical records, progress notes with the nutritional care of the patient met in accordance with the doctor’s orders which includes the nutrition therapy, and the patient’s progress from the nutrition therapy documented by the nutritionist.

I think medical records will only be complete if a patient at nutrition risk undergoing nutrition therapy has his or her medical record showing progress notes from the nutrition therapy documented by the nutritionist. This particular instance of medical record completeness must be satisfied irrespective of your type of hospital, either it is or it is not already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, but if it is, then your hospital will need to comply with JCI Standard COP.5 which requires that “Patients at nutrition risk receive nutrition therapy.”

If JCI Standard COP.5 and its four (4) Measurable Elements are complied satisfactorily, then your medical record also complies with the JCI Standard MCI.19.1 which states that “The clinical record contains sufficient information to identify the patient, to support the diagnosis, to justify the treatment, to document the course and results of treatment, and to promote continuity of care among health care practitioners.”

Before I end, some of you may be wondering what’s the difference between a dietitian and a nutritionist? I am not going to elaborate much on this but since I have used the terms dietitian and nutritionist in three related posts on nutrition,  I know for certain that dietitians and nutritionists are both food and nutrition experts respectively. You may find out more on dietitians and nutritionists from the Academy of Nutrition and Dietetics (United States) and from the University of Maryland Medical Center, United States. Some say dietitians are considered to be nutritionists, but not all nutritionists are dietitians.

References:

  1. Catherine, AR, Benjamin, C, Robert, JC, Katherine, LT & Thomas, LT (eds.) 2014,  Modern nutrition in health and disease, 11th ed, Lippincott Williams & Wilkins, Philadelphia, USA
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Sylvia, ES 2012, Nutrition and diagnosis-related care, 7th edn, Lippincott Williams & Wilkins, Philadelphia, USA

Surgical information that require documentation in medical records

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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.

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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

Diagnostic procedures

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A Health Information Management (HIM) / Medical Records (MR) practitioner will find a series of diagnostic tests or diagnostic procedures – terms used interchangeably, incorporated into the medical record of a patient.

Diagnostic tests or procedures are necessary to formulate a medical diagnosis and the course of treatment based on a patient’s history and presenting symptoms. Diagnostic tests or procedures are also performed to determine abnormalities or disorders of various body systems to identify and to prioritise the treatments and procedures during periodic reassessment and evaluation of the patient’s expected outcomes.

In the post Plan Of Care (this link will open in a new tab of your current window) about individualised care plans, you can read to know about a patient’s care plan which is always related to his or her identified needs. But those needs may change as the result of clinical improvement or new information from a routine reassessment, for example from diagnostic tests such as abnormal laboratory or radiography results.

As diagnostic tests or procedures are expensive, they are prescribed usually selectively by the prescribing practitioner, who is either the doctor in most instances or other authorised  prescribing practitioners like advanced practice registered nurses who are authorised to order and perform certain diagnostic tests.

Diagnostic tests or procedures are either noninvasive or invasive. Noninvasive means the body is not entered with any type of instrument. The skin and other body tissues, organs, and cavities remain intact. Invasive means accessing the body’s tissue, organ, or cavity through some type of instrumentation procedure.

If you are working as a HIM/MR practitioner in a Joint Commission International  (JCI) accredited hospital or a hospital seeking JCI accredited status or infact at any hospital, the medical records show documentation evidence of doctors who had found an abnormality and had prescribed diagnostic tests or procedures to evaluate findings more closely. The JCI Standard COP.2.3 requires that such evidence be demonstrated in the patient’s medical record.

As the JCI Standard COP.2.3 intent statement specifically lists endoscopy and cardiac catheterisation diagnostic procedures, I shall provide some brief details on these diagnostic precudures.

Endoscopy is an invasive diagnostic technique using specialised instruments called endoscopes such as the sigmoidoscope, colonoscope, gastroscope, bronchoscope, and laryngoscope, for visual observation of internal organs through the intestinal tract. However, no incisions are made for routine endoscopy procedures.

 A team of doctors, nurses, and technicians perform a cardiac catheterisation procedure, which takes from 1 to 3 hours to obtain information about congenital or acquired heart defects, measure oxygen concentration, determine cardiac output, or assess the status of the heart’s structures and chambers. Therapeutic treatments may be done during the catheterisation to repair the heart, open valves, or dilate arteries.

Whatever the reason for diagnostic tests or procedures, diagnostic tests or procedures performed and the diagnostic findings (results) are always incorporated into the patient’s medical record. Such documentation on the appropriate forms will indicate details like the identity of the prescribing practitioner and his or her reason for performing the diagnostic and other procedures, if he or she had administered any anesthesia, dye, or other medications, type of specimen obtained and where it was delivered, vital signs and other assessment data such as patient’s tolerance of the procedure or pain and discomfort level as well as any symptoms of complications, patient or family teaching and demonstrated level of understanding  and written instructions given to the patient or family members about the diagnostic and other procedures.

A HIM/MR practitioner must will be able to differentiate between diagnostic and other procedures performed and the location of their diagnostic findings(results) from that for surgical procedures, a written surgical report or a brief operative note that can be found in the patient’s medical record.

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

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

Plan Of Care

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Problems are identified from the initial medical and nursing assessments for each patient, and a plan of care (POC) is implemented soon after by the responsible physician, nurse, and other health professionals with the involvement of the patient and family to address these problems using the data from the initial assessments.

Image credit : todaysseniorsnetwork.com

The POC is a written guide that organises data about a patient’s care into a formal statement that will be used to help the patient achieve optimal health. Therefore, a carefully formulated written plan of care is developed within 24 hours of admission as an inpatient in order to provide quality patient care by prioritising problems and addressing short- and long-term needs of the patient by prioritising treatments, setting realistic goals and developing expected outcomes (outcome identification), planning medical and nursing interventions (with collaboration and consultation between care providers as needed) to meet the patient’s needs, and finally documenting the care plan.

Systematic monitoring and observation performed by the patient’s health care practitioners related to specific problems during ongoing assessments (reassessment) allow to determine the patient’s response to medical and nursing interventions and to identify any emerging problems so as to update the plan as appropriate or to confirm the validity of the data obtained during the initial assessments, thus allowing in compiling a comprehensive database of the patient’s health to achieve the desired outcomes.

Reassessment detect the patient’s changing needs as the result of clinical improvement or new information from a routine reassessment (for example, abnormal laboratory or radiography results), or they may be evident from a sudden change in the patient’s condition (for example, loss of consciousness). The plan for the patient’s care also changes.

The Joint Commission International (JCI) Standard COP.2.1 requires the documentation of a single, integrated care plan that identifies measurable progress (goals) expected by each discipline as opposed to the entry of a separate care plan by each practitioner. This individualised plan of care related to his or her identified needs must be evident for each patient in the patient’s medical record.

During the accreditation survey, the reviewer looks for evidence of an organised and systematic method of monitoring and evaluating patient care that is reflected through changes in the documentation of the medical record as notes to the initial plan or as revised or new care goals, or in a new plan.

The Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital with JCI accreditation status or one that is seeking accreditation status must ensure that all medical records are complete with a  POC.

Medical records will be used to proof evidence of POC for each patient to fully meet the seven (7) requirements for this standard which ensures compliance with JCI’s plan of care requirements as follows :

  1. The care for each patient is planned by the responsible physician, nurse, and other health professionals within 24 hours of admission as an inpatient
  2. The planned care is individualised and based on the patient’s initial assessment data
  3. The planned care is documented in the record in the form of measurable progress (goals)
  4. The anticipated progress (goals) is updated or revised, as appropriate, based on the reassessment of the patient by the interdisciplinary health care practitioners
  5. The care planned for each patient is reviewed and verified by the responsible physician with a notation in the progress notes
  6. The planned care was provided
  7. The care provided for each patient is written in the patient’s record by the health professional providing the care

Since Standard COP.2.1 clearly states the POC provided to each patient is planned and written in the patient’s record by the health professionals providing the care, justifies this standard to be included as medical information.

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

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