Category Archives: JCI Standards MCI

JCI Standard MCI.19 Patient Clinical Record

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I continue my tirade(certainly not trading an angry or violent speech here, but what I actually mean is trying to strongly  inform you that more than working behind the confines of the HIM/MR Department walls you work in, there exists overseeing matters that we need to pay attention at the same time) on STANDARDS for example, JCI’s standards for Management of Communications and Information (MCI) chapter.

In my earlier post on JCI Accreditation Standards for Hospitals – Introductory Post, I started off with mention of the MCI standards chapter, and subsequently dwelled on the its first standard in the JCI Standard MCI.1 post.

Here now before I discuss other standards of MCI, I like to direct you to one subject matter dearest to all of you as HIM/Medical Records professionals.

The matter is about the Patient Clinical Record, be it paper based or EMR. I think the concepts hold true for both media.

Let us look at the standard pertaining to a Patient Clinical Record, which is MCI.19

The structure of this standard is made of one main standard(MCI.19), four sub-standards(MCI.19.1, MCI.19.2, MCI.19.3  and MCI.19.4 ) and one sub-sub-standard(MCI.19.1.1), all pertaining of course to a Patient Clinical Record – this categorisation is entirely mine, just to makes things easier to understand I think (at least for me) and clearer.

The standards as quoted from JCI’s manual, page 231 goes like this:

  • MCI.19 The organization initiates and maintains a clinical record for every patient assessed or treated.
  • MCI.19.1 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.
  • MCI.19.1.1 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.
  • MCI.19.2 Organization policy identifies those authorized to make entries in the patient clinical record and determines the record’s content and format.
  • MCI.19.3 Every patient clinical record entry identifies its author and when the entry was made inthe record.
  • MCI.19.4 As part of its performance improvement activities, the organization regularly assesses patient clinical record content and the completeness of patient clinical records.

Knowing these standards will help us know if our records keeping ways do keep up with a benchmark, in this instance that set by JCI. In this way, I believe we can then excel in records keeping and maintain high standards of professionalism in our work.

Pals, I am aware I am taking you into a discourse deeper and deeper related to a techinical discussion.

I wish and I shall try to relate to these standards with a social theme, since I did profess that this website-blog would be largely a social medium, but sadly it does not seem so as I do not see any interaction of ex-colleagues nor persons actively engaged still in HIM/Medical Records. My intention is to get people talking here, so this website-blog behaves like a social media thing where people connect and exchange views and as examples, to know where each other are located and working at and for whom, how they are doing in their chosen profession etc.

Nevertheless, I shall discuss more on MCI.19 in a future post.

JCI Standard MCI.1

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I am going to watch a movie on ASTRO Fox Movies Premium after this, and cannot help but post this off as I have finished it already.

Pals, I need to stop blogging here pretty soon, as I got other blogs to maintain as well, amongst which – one in particular, so posts here will be delayed or less frequent, unless I am fully energised and wish to rush a post here.

So here goes!

In the JCI Accreditation Standards for Hospitals – Introductory Post dated May 23, 2012 I had posted about the Management of Communication and Information (MCI) function and its direct and indirect relationship to the management of medical records.

In this post I shall talk about the first standard under this MCI function, namely “Communication with the Community, MCI.1” which states “The organization communicates with its community to facilitate access to care and access to information”.*

As part of a hospital, the Malaysian Medical Records Department (MRD) communicates directly to individuals but it is not normally authorised to communicate through public media and through agencies within the community or third parties.

There are 21 standards for this function, including 4 sub-standards and one sub=sub-standard for standard MCI.19, and 2 sub-standards for standard MCI.20.

Each standard has specific requirements. The Measurable Elements (MEs) are these specific requirements for each standard. The MEs simply list what is required to be in full compliance with the standard. The MEs will be reviewed and assigned a score during the accreditation survey process.

For MCI.1, the MEs measure the compliance of the MRD of the hospital to the requirements of this standard.  The MEs measure if:

  • the MRD has identified its communities and populations of interest.
    • I think these defined key groups will include all forms of patient contact with the hospital such as emergency care patients, outpatients discharged patients, and non-patient groups like the next of kin, members of the general public, students, the Polis, and sometimes even members of the Press and Media.
  • there is a communication strategy plan incorporating an on-going communication plan with its defined key groups of their communities and patient populations
  • there is information provided to the public and to referral sources on MRD services, hours of operation, and the process to obtain care
  • the MRD provides information on the quality of services to the public and to referral sources

If the MRD fully meets these requirements (full compliance), then I think the MRD as part of the organisation, has succeeded in communicating with its community to facilitate access to care and access to information.

Please note that this standard also applies to other departments of the hospital that also communicate with the community to facilitate access to care and access to information, for example the Public Relations Department.