Category Archives: JCI Standards MCI

Malaysian Medical Council (MMC) – acceptable contents of a patient’s medical record

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Further to the acceptable norm for medical record contents, and qualified by the JCI Standard MCI.19.1 which states that “The patient 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”, HIM/MR practitioners in Malaysia need to take note that the Malaysian Medical Council (MMC) recommends  the following items which may make up the contents of a patient’s medical record – perhaps other countries also have similar guidelines :

  • Doctor’s clinical notes
  • Recording of discussion with patient/next of kin regarding
    disease/management/possible use of tape recording for such discussions
  • Referral notes to other specialists for consultation/co-management
  • Laboratory reports
  • Imaging records and reports
  • Clinical photographs
  • Drug prescriptions
  • Nurses’ reports
  • Consent forms
  • Operation notes/anaesthetic notes
  • Video recordings
  • Printouts from monitoring equipment
  • Correspondence with other healthcare professionals
  • Computerised/electronic records
  • Recordings of telephone consultations.

Source: mmc.gov.my/v1/

JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record

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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.

JCI MCI19.1 & MCI19.1.1 – Patient Clinical Record

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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.


JCI Standard MCI.1 – brochure example

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In my previous post JCI Standard MCI.1, I talked about the “Communication with the Community” and how the HIM/MR Department communicates with its community to facilitate access to care and access to information provided by the HIM/MR Department of a hospital.

I like to share with you (with expressed permission) this brochure (file will open in a new tab of your current window of your browser) from St Vincent’s Hospital Sydney Ltd, a facility of St Vincents & Mater Health Sydney, Darlinghurst, NSW, Australia. I have always admired the Aussies for a high standard in documentation!

I think it is a good brochure on communication with the community about the privacy of a patient’s health information.

JCI Standard MCI.19 Patient Clinical Record – a review

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In continuation to the post JCI Standard MCI.19 Patient Clinical Record, the first standard, its intent and the measurable elements are:

Standard MCI.19
The organization initiates and maintains a clinical record for every patient assessed or treated.

Intent of MCI.19
Every patient assessed or treated in a health care organization as an inpatient, outpatient, or urgent care patient has a clinical record. The record is assigned an identifier unique to the patient, or some other mechanism is used to link the patient with his or her clinical record. A single record and a single identifier enable the organization to easily locate patient clinical records and to document the care of patients over time.

Measurable Elements of MCI.19

  1. A clinical record is initiated for every patient assessed or treated by the organization.
  2. Patient clinical records are maintained through the use of an identifier unique to the patient or some other effective method.

Examining the intent and the measureable elements for this standard from above, I think it is important to know answers to the following questions:

Does your hospital initiate and maintain a clinical record for every patient assessed or treated?

A patient or clinical record is defined (Michelle, A.G. & Mary J.B. 2011, pg 70) “as the business record for a patient encounter, contains documentation of all health care services provided to a patient, and is a repository of information that includes  demographic data, as well as documentation to support diagnoses, justify treatment, and record treatment results.”1

1Essentials of Health Information” (Michelle, A.G. & Mary J.B. 2011, Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, New York

So since your hospital initiates and maintains a clinical record for every patient assessed or treated, who are these kinds of patient at your hospital?

Hospital patients are usually categorised as ambulatory patients (outpatients), ambulatory surgery patients(e.g., day surgery), emergency care patients, inpatients, newborn patients, observation care patients, and subacute care patients.

Now that you have identified your list of patient types/categories, how do you identify each of these identified groups of patients? State your method and how does it work?

Do you provide a single clinical record or multiple records?

Does your method use an unique identifier? If so, what is this unique identifier?
The Medical Record Number(MRN) is commonly used as this unique identifier.

How do you maintain your patient clinical records?
The above standards do not specify methods for record management,  all hospitals must implement systems to effectively manage and control records.
In addition, filing controls are established to ensure accurate filing and timely retrieval of patient records, including:

  • Chart tracking system (they could be manual or computerised)
  • File guides
  • Periodic audit of file system

It is the intent of this standard that using an unique identifier, your hospital can easily locate patient clinical records and to document the care of patients over time. How do you locate your patient clinical records using this unique identifier?

How do you link the patient with his or her clinical record?

A master patient index (MPI), sometimes called a master person index (MPI), links a patient’s medical record number with common identification data elements (e.g., patient’s complete name, date of birth, gender, mother’s maiden name, and social security number).

If your unique identifier is the MRN, then how is your MPI used to link the patient with his or her clinical record?

Your answers to the above questions must be outlined in the HIM/MR departmental policies and procedures. Your answers will provide the JCI surveryor(s) the opportunity to evaluate the compliance to this standard and chances are, he or she will give a full compliance score for this standard, if all is in order and well documented and answers answered well!