Category Archives: MCI.13

JCI Standard MCI.13 – Use of standardised diagnosis codes, procedure codes and definitions

Posted on by
Reply

As a Health Information Management (HIM) / Medical Records (MR) practitioner, you will be very familiar with data collected in manual forms and in electronic systems along with the clinical and medical terms the care providers use  in your hospital to document the patient care.

To go on with the Joint Commission International (JCI) Standard MCI.13 from my previous post JCI Standard MCI.13 – Use of standardised symbols and abbreviations (this link will open in a new tab of your current browser window), I think you need to know a little introduction about data since you will be part of the Management of Communications and Information Committee discussing along side with a representative from the hospital Information Technology (IT) department. The Joint Commission International (JCI) Standard MCI.13 does not specify a need to know about data elements and the workings of a Hospital Information System (HIS).

A piece of data that you encounter each day is the data element, which is a basic unit of information collected about anything of interest – for example, a pharmaceutical name or the city in which a patient lives. All the data elements reside in a data dictionary which is a collection of data element and their definitions. The data set refers to a commonly agreed upon collection of data elements found in your HIS and is a standard method for collecting and reporting these individual data elements. The data set used for collection and reporting purposes depends on patient type, for example a data set for oncology (study of cancer) when data is collected on cancers in acute care hospitals and reported to a national cancer registry nationwide.

What a HIM/MR practitioner does need to know that concerns this standard is about what is a medical vocabulary, medical nomenclatures, and classification systems.

A nomenclature is a systematic listing of the proper names. When health care providers document patient care they use a medical nomenclature, for example the Systematized Nomenclature of Medicine (SNOMED) which is a vocabulary of clinical and medical terms (e.g., myocardial infarction, diabetes mellitus, appendectomy, and so on), is used in more than 40 countries (Prathibha 2010).

Medical vocabulary is a system of disease names with explanations of their meanings. A medical coding system (or medical classification system) then organises the clinical and medical terms in a medical vocabulary (the medical nomenclature) into categories according to similar conditions, diseases, procedures, and services and establishes codes (numeric and alphanumeric characters) for each.

Several medical classification systems exist, of which any HIM/MR practitioner  would be most familiar with is ICD-10, which is entitled the International Statistical Classification of Diseases and Related Health Problems (ICD-10). While most WHO member states had started to adopt ICD-10 by 1994, the health care system in the United States continues to use the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) as its official system of assigning codes to diagnoses and procedures related to hospital use. Also in the U.S., ICD-10-PCS, a procedural classification system is intended to replace ICD-9 volume 3 for reporting of inpatient procedures while Current Procedural Terminology (CPT) is still used for all outpatient procedures.

Diagnoses and procedures codes are reported to third-party payers for reimbursement as in the U.S., to external agencies for data collection, and internally for education and research in most countries. Standard terminology enables data capture to proceed in a structured manner, facilitating the collection of information and enhancing the ability to perform data analyses.

Your hospital will be checked for compliance to this standard and hopefully your hospital is prepared to fully meet the four (4) measurable elements of JCI Standard MCI.13 which measure if (i) only standardised diagnosis codes and procedure codes for example ICD-10 or ICD-10 PCS are used and monitored, and (ii) standardised definitions, symbols,  and abbreviations are used and their usage monitored but (iii) ensuring that those symbols and abbreviations not to be used are identified and monitored as well.

Potential sources of errors at each step of the disease coding process using standardised diagnosis codes and procedure codes must be monitored by the HIM/MR department during routine and/or random checks of medical records to ensure code accuracy. Increased attention  to monitoring code accuracy is important as it directly impacts the quality of decisions that are based on codes as a result of the application of ICD codes for purposes other than those for which the classifications were originally designed as well as because of the widespread use for making important funding for example casemix, clinical, and research decisions.

Standardised definitions, symbols, and abbreviations use – taking into account those symbols and abbreviations that are not to be used (that is the Do Not Use List) must be monitored as  I posted in my previous post JCI Standard MCI.13 – Use of standardised symbols and abbreviations (this link will open in a new tab of your current browser window).

A hospital must also ensure that standardisation of diagnosis codes and procedure codes, definitions, symbols,  and abbreviations usage is consistent with recognised local and national standards and even international standards and best practices.

With this post, I think I briefly blogged about the implications of JCI Standard MCI.13 and your role as a HIM/MR practitioner in ensuring compliance to this standard.

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

Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn,  Jones and Bartlett Publishers, Sudbury, MA, USA

JCI Standard MCI.13 – Use of standardised symbols and abbreviations

Posted on by
1

The Joint Commission International (JCI) Standard MCI.13 is about the uniform use of standardised diagnosis codes, procedure codes, symbols, abbreviations (which includes a “do not use” listing), and definitions in a hospital which supports data aggregation and analysis and which facilitates comparison of data and information within and among organisations by using such standardised terminology, definitions, vocabulary, and nomenclature consistent with recognised local and national standards.

I shall be writing in the context of what a Health Information Management (HIM) / Medical Records (MR) practitioner on a need-to-know and what-to-do basis about this standard and its intent. To write all about the intents of this standard will take several posts, and I do not wish to be publishing text-book material here. I only plan to blog about what you need to know as an HIM/MR practitioner and what you need to plan and implement for your role as a HIM/MR practitioner, from the perspective of a quality practitioner with the background of as a HIM/MR practitioner.  I do not intend to publish a long posts, so this post is all about an official (approved) abbreviation list and the first post of a series of posts on the JCI Standard MCI.13, perhaps covering 2 or 3 more posts.

I believe every hospital  should establish a policy to maintain an official (approved) abbreviation list as to which abbreviations, acronyms, and symbols (and their meanings) can be documented in the patient record.

One does not wait for his or her hospital to be seeking JCI or other agency hospital quality assurance accredited status before embarking on a policy and an approved abbreviation list.

Here I am listing tasks for the HIM/MR practitioner and the Medical Records Committee (MRC) of a hospital :

  1. the HIM/MR practitioner should initiate an approved abbreviation list for discussion during a MRC meeting if he or she finds there in no approved abbreviation list or if the existing one needs a much-needed revision
  2. the MRC should set a dateline for medical-staff of the hospital to review and submit a revised list by distributing the existing list
  3. if there is no existing list, the HIM/MR practitioner should source for a sample list which can be downloaded from many Internet websites (check for copyright information; if written permission is required to reproduce, then it is wise to write to the copyright owner)
  4. modify and customise for local use, present at the MRC meeting and if approved for distribution, distribute to medical-staff of the hospital to review and submit a revised list by a set dateline
  5. the revised abbreviation list of an existing list or a newly created abbreviation list after review should be presented to the MRC
  6. the Chairman of the MRC who is usually a clinician, would then make it easier the task of final approval of this abbreviation list by using his or her influence among fellow clinicians in all medical disciplines of the hospital for consensus
  7. the abbreviation list is deemed finally an approved abbreviation list after one last meeting agenda to approve it officially at a scheduled MRC meeting
  8. the abbreviation list is forwarded to the hospital top management for final approval and signature before it is formated in an appropriate format and printed for distribution to all disciplines and patient care areas of the hospital
  9. a hospital policy must be created by the HIM/MR practitioner to document the approved abbreviation list as to which abbreviations, acronyms, and symbols (and their meanings) can be documented in the patient medical record of the hospital.

If your hospital is already JCI accredited, I am taking a guess the Management of Communication and

Information (MCI) Committee (MCIC) which has oversight on all matters pertaining to MCI, had initiated the approved abbreviation list of a revised existing list or created a new approved abbreviation list. The MCIC notifies the MRC about the necessity for compliance to JCI Standard MCI.13, and the MRC carries out tasks outlined as above for a hospital already JCI accredited or a hospital seeking JCI accreditation.

Usage of abbreviations, acronyms, and symbols found in the medical record during routine and/or random checks is monitored by the HIM/MR Department for any hospital. For JCI accredited or JCI accreditation seeking hospitals, checks are also done during a Medical Records  Review process session(s) and unapproved abbreviations, acronyms, and symbols  checked against an approved abbreviation list are documented and reported in a report to the Medical Records  Review Committee (MRRC) which in turn then forwards its meeting minutes highlighting anomalies from the report to the MCIC. The MCIC sends in a report or a letter to the MRC Chairman for his or her attention and appropriate action.

Before I end this post, I need to say that the JCI standards have not explicitly required an approved list of abbreviations. However, a “do not use” list which is a  “(JCI 2011) written catalog of abbreviations, acronyms, and symbols that are not to be used throughout a hospital – whether handwritten or entered as free text into a computer – due to their potentially confusing nature”, it is appropriate that a “do not use” list forms a part of the approved abbreviations list. You can view the Official Do Not Use List as it stands today released in 2004 by the Joint Commission (UnitedStates)  after you download it from
http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf (this link will open in a new tab of your current browser window).

My post on an approved abbreviation list ends here, and allow me to continue in my next post more on other concerns of the JCI Standard MCI.13

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