The Standard MCI.19.1 states “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” , while the Standard (sub-standard) MCI.19.1.1 states that “The clinical record of every patient receiving emergency care includes the time of arrival, the conclusions at
termination of treatment, the patient’s condition at discharge, and follow-up care instructions”.

The clinical record is only complete and can satisfy the above standards if your hospital has implemented a standarised medical record format and content of a patient’s clinical record to help promote the integration and continuity of care among the various practitioners of care to the patient.

Let us now view as below the standards, their respective MEs, and how I suggest (my suggestions in brown) each of these MEs can meet full compliance for these two standards (double-click on each of the following images BELOW for a larger view of each image which will then display in a new tab of the current window of your browser) :

NOTE: With the exception of MCI.19.1 and MCI.19.1, all the other standards in this post refer to other forms of entries in the patient clinical record.