MCI.19.2 |

The individual responsible for the coordination of the patient’s care must be identifiable and available through all phases of inpatient care as the patient moves through a hospital from admission to discharge or transfer, several departments and services and many different health care practitioners who may be involved in providing care. Thus if a patient Nancy is under constant professional supervision, making handoffs efficient and accurate and this creates continuity throughout Nancy’s care. Since she is always in contact with trained staff, any new information regarding her behaviour will be properly notated and added to her medical records file.

In the United States, the National Quality Forum had identified in a 2006 report (Barbara 2011 p.72) the practice of information management in the medical record to document the continuity of care to matching healthcare needs with service capability, as one of the 30 safe practices that basically helps to create and sustain a culture of safety with the eventual goal “to improve the things that help and prevent the things that harm”.

In fact, the continuity of care (or continuum of care) is among a list of indicators (Judith, H and Paul, D 2009) including access, effectiveness, communication and participation, care and physical comfort, human needs, efficiency, information, and involvement of family and friends on quality care as identified by consumers (patients) who prefer holistic health care and published by the Picker Institute in Europe.

The opportunity to assess continuity of care issues to “trace” the care experiences that a patient had during his or her stay in the hospital is often used in the individual patient tracer activity conducted during the on-site survey under Tracer methodology, which is an evaluation method used to analyse a hospital’s system of providing care, treatment, and services using actual patients as the framework for assessing a hospital’s Joint Commission International (JCI) international standards compliance, i.e a hospital which is already accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status. The medical records of patients currently receiving care in the unit/setting are often used in such evaluations.

As continuity of care is a critical component of patient safety, Health Information Management (HIM) / Medical Records (MR) practitioners must be able to identify who is the responsible individual expected to provide documentation related to the patient’s plan of care because this individual is usually identified in the patient’s medical record or in another manner made known to the hospital’s staff, for example a list of doctors and their specimen signatures.

HIM / MR practitioners are expected to know that this single individual may be a doctor or other qualified individual who has the overall responsibility for coordination and continuity of the patient’s care or particular phase of the patient’s care. This individual is or was providing the oversight of care for a patient during the entire hospital stay which will improve continuity, coordination, patient satisfaction, quality, and potentially the outcomes and thus is desirable for certain complex patients and others in the hospital.

Patients may be delivered in a wide range of community and hospital-based settings and moved from one phase of care to another (for example, from surgical to rehabilitation). The ability to share information between these settings may be limited and fragmented, as a result what usually happens is delays in care when health care providers who are poorly informed ‘reinvent the wheel’ and begin to duplicate procedures and investigations. If the individual originally responsible for the patient’s care continues to oversee all the patient’s care, then a reduction in the quality of care will not be likely nor will it impair continuity of patient care or threaten the patient’s safety. But if this individual originally responsible for the patient’s care changes, this individual would need to collaborate and needs to communicate with the other health care practitioners.

What if the patient goes to multiple doctors in multiple settings that do not have an integrated information system when the health care delivery organisation cannot provide coordination and continuity? I think a patient can take charge of his or her data although it is a challenging responsibility, and so I would advocate and believe that the personal health records approach can bring together a patient’s health information.

If you are a HIM / MR practitioner practising at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then beware that the JCI Standard ACC.2.1 which states that “During all phases of inpatient care, there is a qualified individual identified as responsible for the patient’s care.”

This will require you to:

be aware that the process of continuity of care according to Michelle and Mary (2011, p.71) includes “documentation of patient care services so that others who treat the patient have a source of information from which to base additional care and treatment”
be able to identify from the medical record the individual responsible for the coordination of the patient’s care through all phases of inpatient care had duly provided documentation in the clinical record related to the patient’s plan of care
maintain a list of individuals who are qualified to assume responsibility for the patient’s care and who can be identified to the hospital’s staff by using a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries; I had covered on this aspect in the post JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record
(this link will open in a new tab of your current browser window)
be aware that other consultants, on-call doctors, locum tenets, or others take responsibility of the patient as identified in a hospital policy that identifies the process for the transfer of responsibility from the responsible individual to another individual during vacations, holidays, and other periods and they assume this responsibility when they duly document their participation/coverage in the medical record
be aware that the JCI Standard ACC.2.1 is included in the Medical Records Review Tool

References:

Barbara JY (ed.) 2011, Principles of risk management and patient safety, Jones & Bartlett Learning, Sudbury, MA, USA
Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA
Judith, H and Paul, D (eds.) 2009, Patient Safety First Responsive Regulation In Health Care, Allen & Unwin, New South Wales, Australia
Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Its been 7 days since I last posted on quality standards for patient clinical records.

To continue on JCI hospital accreditation standards, this Thursday morning I am posting away this post drafted over the last 4 days, sharing with you my experiences on the JCI Standard MCI.19.2 and JCI Standard MCI.19.3. These 2 standards relate to the quality of patient clinical records.

JCI Standard MCI.19.2 states that “organization policy identifies those authorized to make entries in the patient clinical record and determines the record’s content and format”.

Thus, the person(s) who have the authority and right to document in a patient clinical record must be as defined by the hospital’s policy. This would mean all writers who document in a patient clinical record – doctors especially, must be trained in and/or briefed and follow their hospital’s standards and policies for documentation.

A hospital policy for patient record documentation must define by job title and function, including students in academic settings as those authorised to make entries in the patient clinical record The policy must determine the format and location of entries, contain a process to ensure that only authorised individuals make entries in patient clinical records, contain a process that addresses how entries in the patient record are corrected or overwritten, provides identities of those authorised to have access to the patient clinical record and thereby have the obligation to keep the information confidential, and also contains a process to ensure that only authorised individuals have access to the patient clinical record and if information is compromised then it also contains a process to be followed when confidentiality and security are violated. If your hospital policy satisfies these provisions, then the MEs of MCI19.2 surely be in full compliance (graphic below gives a summary of the policy, double-click on graphic for a larger view of this graphic in a new tab, of the same window of your browser).

In Malaysia, training and awareness on the right to document in patient clinical records by doctors begins during their internship. “A Guidebook for House Ofﬁcers”, published 23 April 2008 by the Malaysian Medical Council, clearly states that “in Malaysia, pursuant to the Medical Act 1971, internship is only imposed upon after graduation. The two-year internship combines service and training roles. It is formulated in such a way to ensure medical practitioners like you gain appropriate knowledge, skill and experience as well as correct attitude rather than merely employment and provision of services”. This training roles includes that regarding documentation in the patient clinical record as in section 4.4, page 32 of this guidebook.

If the author, the date and the time for each patient clinical record entry especially for timed treatments or medication orders can all be identified successfully, then you patient record satisfies the Standard MCI.19.3 which states that “every patient clinical record entry identifies its author and when the entry was made in the record”.

However the requirement that the author, the date and the time for each patient clinical record entry especially for timed treatments or medication orders, must be stipulated in the hospital policy.

I think it is also wise to include in the policy that the authors should sign with their legal signature (your last name and legal first name or initials), no nicknames should be used, and initials should follow their name indicating their status as a specific caregiver, depending on local statutes and regulations which I think is lacking in Malaysia, but take note that this is not required(no mention) by JCI Standard MCI.19.3

I did not cover in this post about counter-signatures, telephone order (T.O.), voice order (V.O.), Fax Signatures, Electronic Signatures, and Signature Stamps, but of course all these other modes of documentation entries can be included in the policy.

Here I remember the familiar ISO 9001 cliché “say what you do and do what you say”, is to document everything that everyone does. You also must have heard the “wasn’t documented, wasn’t done” motto which is a common one in healthcare settings.