Category Archives: JCI Standards COP

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.

Process to integrate and to coordinate the care provided to each patient

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The previous post Collaboration, and the holistic care of the patient (this link will open in a new tab of your current window), discussed collaboration between members of an interdisciplinary health care team in a hospital comprising of medical, nursing, and other individuals and services responsible for patient care when they use an interdisciplinary approach to analyse and to integrate patient assessments through which they identify the most urgent or important care needs for the patient.

Any results or conclusions from collaborative patient care team meetings or similar patient discussions reflecting this integration and coordination of care are written into the patient’s medical record showing each practitioner’s own observations and treatments.

If there is documentation in the medical record of patients as evidence of a process to integrate and to coordinate the care provided to each patient in the hospital, then this evidence meets the  Joint Commission International (JCI) requirement for the Standard COP.2 which states “There is a process to integrate and to coordinate the care provided to each patient”.

Integrating and coordinating care planning and care delivery among settings, departments, and services meets the JCI Standard COP.2 and the requirements ME1 and ME2. Documenting the results or conclusions of any patient care team meetings or other collaborative discussions in the patient’s medical record in turn meets the JCI Standard COP.2 requirement ME 3.

A Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital with JCI accreditation status or one that is seeking accreditation status, must know how the patient’s medical record facilitates and reflects the integration and coordination of care when each practitioner records observations and treatments in the patient’s medical record. Also, when any results or conclusions from collaborative patient care team meetings or similar patient discussions are written in the patient’s medical record.

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

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

JCI Standard MCI.19.4 – Patient Clinical Record, the “quality oversight mechanism“

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It is a common sight in hospitals as doctors and nurses make their rounds assessing patient needs and providing care. It is not uncommon as managers, support staff like HIM/MR professionals, and others in a hospital also make their rounds around their tasks assessing processes and resources and exercise set professional standards to their daily work, thereby understanding how processes can be more efficient, how resources can be used more wisely, and physical risks(safety) to the patients and staff can be reduced.

Thus, quality and safety is entrenched in the needs and care of patients as individual health care professionals and other staff execute their daily work.

As these individual health care professionals and other staff go about their daily work, the organisation continuously plans, designs, measures, analyses, and improves clinical and managerial processes to achieve maximum benefit from its quality and safety efforts.

It is no doubt to my mind that all these efforts to get quality and safety measures well organised requires no less clear leadership, needs some kind of mechanism and an organisational framework to oversee and improve those processes. As most clinical care processes, managerial processes and quality issues are interrelated and involve more than one department or unit and may involve many individual jobs, accentuates the need for clear leadership, a mechanism to work around with the help of an organisational framework for quality and safety.

This framework will develop greater leadership support for an organisation wide program, train and involve more staff, set clearer priorities for what to measure, base decisions on measurement data, and make improvements based on comparison to other organisations, nationally and internationally.

The framework and the mechanism to guide quality improvement and patient safety efforts in a hospital rest with a quality improvement and patient safety oversight group or committee.

All of the above explains  the “quality oversight mechanism“ I talked about in the post JCI Standard MCI.19.4 – Patient Clinical Record.

Abridged, and adapted from Quality Improvement and Patient Safety (QPS), Governance, Leadership, and Direction (GLD), and Management of Communication and Information (MCI) chapters of the JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 4th Edition