Category Archives: COP.2.2

Postings about medical documentation

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When I wrote “With this post, I believe I have covered postings about medical documentation found in a typical medical record and their relationship to the relevant JCI standards.” at the end of the post Collaboration, and the holistic care of the patient (this link will open in a new tab of your current window), I inadvertently missed out posting about the Standard COP.2.2 of the Joint Commission International (JCI) which is about “Those permitted to write patient orders write the order in the patient record in a uniform location”. and also about the Standard COP.2 which states “There is a process to integrate and to coordinate the care provided to each patient”. Actually the Standard COP.2 is linked with the standards I discussed under Collaboration, and the holistic care of the patient (this link will open in a new tab of your current window), i.e Standard AOP.4 and Standard AOP.4.1. I discussed Standard COP.2 under the post Process to integrate and to coordinate the care provided to each patient (this link will open in a new tab of your current window),

Since written patient orders as well as the results or conclusions of any patient care team meetings or other collaborative discussions written in the patient’s record are both medical documentation, I rushed to post about Standard COP.2 and Standard COP.2.2 in the post Process to integrate and to coordinate the care provided to each patient (this link will open in a new tab of your current window) and in the post Written patient orders (this link will open in a new tab of your current window)., respectively.

I think I can safely say now I have finally covered postings about medical documentation found in a typical medical record and their relationship to the relevant JCI standards.

Written patient orders

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Standard COP.2.2 of the Joint Commission International (JCI) is about “Those permitted to write patient orders write the order in the patient record in a uniform location”.

Image credit : http://ecowatch.org/wp-content/uploads/2012/05/drorders.jpg

Each patient care plan includes written orders by individuals qualified to order  and record patient orders, for example diagnostic tests orders for laboratory testing, orders for surgical and other procedures, medications orders, nursing care orders, and nutrition therapy orders.

A uniform location in the patient’s medical record or on a common order sheet which is then transferred to the patient’s medical record periodically or at discharge, facilitates understanding the specifics of an order, when the order is to be carried out, and who is to carry out the order as well as creates easy accessibility to the orders so that orders can be acted upon in a timely manner.

All the four (4) requirements (MEs) of the JCI Standard COP.2.2 will be fully met if the hospital staff are aware and practice what is contained in a hospital policy which among other policy statements also states policies on which orders must be written rather than verbal, which diagnostic imaging and clinical laboratory test orders must provide a clinical indication/rationale, if there any exceptions in specialised settings, such as emergency departments and intensive care units, the staff member who is permitted to write orders and where orders are to be located in the patient’s medical record.

Health Information Management (HIM) / Medical Records (MR) practitioners working in a hospital must be aware and knowledgeable that his or her medical records in his or her custody and care contain orders by individuals qualified to do so.

Orders will be found in all medical records regardless of the type of hospital they work at, whether or not 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