Category Archives: JCI Standards

The anaesthesia used and anaesthetic technique are written in the patient record

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The decision-making process necessary for deciding which anaesthesia to use and the anaesthetic technique to select is the responsibility of the anaesthesiologist, the anaesthesia provider (the health professional providing the care) rendering the anaesthetic care planned for the patient related to his or her identified needs.

The anaesthesia care provider has several options deciding which anaesthetic technique (Ronald & Manuel 2011) to select available including (1) general anaesthetic – usually induced in adult patients by the intravenous administration of an anaesthetic (propofol, thiopental, or etomidate) that produces rapid onset of unconsciousness, (2) regional anaesthetic – spinal (Spinal anaesthesia is accomplished by injecting local anaesthetic solution into the cerebrospinal fluid (CSF) contained within the subarachnoid (intrathecal) space. or epidural (achieved by injection of local anaesthetic solution into the space that lies within the vertebral canal but outside or superficial to the dural sac) or caudal anaesthesia (represents a special type of epidural anaesthesia in which local anaesthetic solution is injected into the caudal epidural space through a needle introduced through the sacral hiatus) are selected when maintenance of consciousness during surgery is desirable, (3) peripheral nerve block – a technique of anaesthesia for superficial operations on the extremities or (4) monitored anaesthetic care (MAC) – a procedure in which an anaesthetic provider is requested or required to provide anaesthetic services, which include preoperative evaluation, care during the procedure, and management after the procedure.

I shall avoid details of the types of the anaesthesia used and the anaesthetic techniques (I have already given enough extracted text-book explanations in the paragraph above of anaesthetic techniques) used. as I think it is only appropriate for me to highlight in this post what needs to be satisfied by a quality assurance requirement, for example the Joint Commission International (JCI) quality Standard ASC.5.2 which requires that “The anaesthesia used and aesthetic technique are written in the patient record.”

It is clear from the intent of this standard that JCI surveyors must be able to find evidence of  the anaesthesia used and anaesthetic technique written somewhere in the patient’s medical  record during a hospital survey process.  The Health Information Management (HIM) / Medical Records (MR) practitioner’s role should be ensure that he or she can identify the location of this evidence in the medical record and contribute to completeness and quality of the medical record.

Anaesthesia providers qualified to administer anaesthesia like an anaesthesiologist, documents patient monitoring when a patient receives an anaesthetic other than a local and other activities related to the surgical episode. Detailed records of the course of anaesthesia are documented in an anaesthesia record, the piece of evidence of the anaesthesia used and anaesthetic techniques used. Preoperative and postoperative visits, and detailed records of the course of anaesthesia, serve as the best protection for the anaesthesiologist or other authorised anaesthetic provider against medico legal action.

Contents of the anaesthesia record in the usual handwritten anaesthetic record documenting the anaesthesia used and the anaesthetic technique used contain adequate information (Michelle & Mary 2011) and  justify the anaesthesia care as follows:

  1. Preanesthesia medication administered, including time, dosage, and effect on patient
  2. Appraisal of any changes in the patient’s condition (since preanesthesia evaluation)
  3. Anaesthesia agent administered, including amount, technique(s) used, effect on patient, and duration, qualifying for full compliance against ME 1 and ME 2 requirements for JCI Standard ASC.5.2
  4. Patient’s vital signs (e.g., temperature, pulse, blood pressure)
  5. Any blood loss
  6. Transfusions administered, including dosage and duration IV fluids administered, including dosage and duration
  7. Patient’s condition throughout surgery, including pertinent or unusual events during induction of, maintenance of, and emergence from anaesthesia.
  8. Authentication by the individual qualified to administer anaesthesia (e.g., certified registered nurse anaesthetist, anaesthesiologist) and names of anaesthesia assistants identified in the patient’s anesthesia record, would then serve to satisfy full compliance with the ME 3 for Standard ASC.5.2

Here is a part of an anaesthesia record (as below) showing the fields for recording anaesthetic technique and anaesthesia agents used (click on the image for a larger view in a new tab of your current browser window).

Source :Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, pg 163

Do take note that preanaesthesia and postanaesthesia evaluation progress notes are sometimes documented on a special form located on the reverse side of the anaesthesia record.

HIM/MR practitioners should also ensure that the medical record contains all records of previous admissions. This is important when an anaesthesia record of a previous surgery which contains historical information, could yield much useful information for the anaesthesia provider especially in the ease of airway management techniques such as direct laryngoscopy when the physical examination by the anaesthesia provider suggests some risk factors for difficult tracheal intubation. If the historical information from the anaesthesia record of this previous surgery clearly documented uncomplicated direct laryngoscopy for a recent surgery, the anaesthesia provider may then proceed with routine laryngoscopy. .

In conclusion, I think the presence of an completed anaesthetic record in a medical record documenting the anaesthesia used and anaesthetic technique, is sufficient evidence to justify full compliance with JCI Standard ASC.5.2

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

Ronald, DM & Manuel, CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA

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

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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

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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

Diagnostic procedures

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A Health Information Management (HIM) / Medical Records (MR) practitioner will find a series of diagnostic tests or diagnostic procedures – terms used interchangeably, incorporated into the medical record of a patient.

Diagnostic tests or procedures are necessary to formulate a medical diagnosis and the course of treatment based on a patient’s history and presenting symptoms. Diagnostic tests or procedures are also performed to determine abnormalities or disorders of various body systems to identify and to prioritise the treatments and procedures during periodic reassessment and evaluation of the patient’s expected outcomes.

In the post Plan Of Care (this link will open in a new tab of your current window) about individualised care plans, you can read to know about a patient’s care plan which is always related to his or her identified needs. But those needs may change as the result of clinical improvement or new information from a routine reassessment, for example from diagnostic tests such as abnormal laboratory or radiography results.

As diagnostic tests or procedures are expensive, they are prescribed usually selectively by the prescribing practitioner, who is either the doctor in most instances or other authorised  prescribing practitioners like advanced practice registered nurses who are authorised to order and perform certain diagnostic tests.

Diagnostic tests or procedures are either noninvasive or invasive. Noninvasive means the body is not entered with any type of instrument. The skin and other body tissues, organs, and cavities remain intact. Invasive means accessing the body’s tissue, organ, or cavity through some type of instrumentation procedure.

If you are working as a HIM/MR practitioner in a Joint Commission International  (JCI) accredited hospital or a hospital seeking JCI accredited status or infact at any hospital, the medical records show documentation evidence of doctors who had found an abnormality and had prescribed diagnostic tests or procedures to evaluate findings more closely. The JCI Standard COP.2.3 requires that such evidence be demonstrated in the patient’s medical record.

As the JCI Standard COP.2.3 intent statement specifically lists endoscopy and cardiac catheterisation diagnostic procedures, I shall provide some brief details on these diagnostic precudures.

Endoscopy is an invasive diagnostic technique using specialised instruments called endoscopes such as the sigmoidoscope, colonoscope, gastroscope, bronchoscope, and laryngoscope, for visual observation of internal organs through the intestinal tract. However, no incisions are made for routine endoscopy procedures.

 A team of doctors, nurses, and technicians perform a cardiac catheterisation procedure, which takes from 1 to 3 hours to obtain information about congenital or acquired heart defects, measure oxygen concentration, determine cardiac output, or assess the status of the heart’s structures and chambers. Therapeutic treatments may be done during the catheterisation to repair the heart, open valves, or dilate arteries.

Whatever the reason for diagnostic tests or procedures, diagnostic tests or procedures performed and the diagnostic findings (results) are always incorporated into the patient’s medical record. Such documentation on the appropriate forms will indicate details like the identity of the prescribing practitioner and his or her reason for performing the diagnostic and other procedures, if he or she had administered any anesthesia, dye, or other medications, type of specimen obtained and where it was delivered, vital signs and other assessment data such as patient’s tolerance of the procedure or pain and discomfort level as well as any symptoms of complications, patient or family teaching and demonstrated level of understanding  and written instructions given to the patient or family members about the diagnostic and other procedures.

A HIM/MR practitioner must will be able to differentiate between diagnostic and other procedures performed and the location of their diagnostic findings(results) from that for surgical procedures, a written surgical report or a brief operative note that can be found in the patient’s medical record.

References:
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

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

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Anaesthesia plan in the patient’s medical record

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A Health Information Management (HIM) / Medical Records (MR) practitioner will find documentation of preoperative activities including each patient’s anaesthesia care which is planned and documented in the patient’s record.

The Joint Commission International (JCI) Standard ASC.5 specifically requires documentation of preoperative activities to include that each patient’s anaesthesia care is planned and documented in the patient’s medical record.

This is true for all patients in the preoperative phase in all hospitals, and not just for hospitals already JCI accredited or seeking JCI or other healthcare quality standards.

After the preoperative evaluation by an anaesthesiologist or another qualified individual as outlined in the post Anesthesia care must be given by a qualified individual (this link will open in a new tab of your current window), anaesthesia care is carefully planned and the anaesthesia plan is created,

The plan includes a list of drug choices and doses in detail, the method of administration, other medications and fluids, monitoring procedures, and anticipated postanesthesia care.

An HIM) / MR practitioner will find documentation of each patient’s anaesthesia care plan as shown in the sample General Anaesthesia Plan below documented in the patient’s medical record.

SAMPLE GENERAL ANAESTHESIA PLAN

Case
A 47-year-old woman with biliary colic and well-controlled asthma requires anaesthesia for laparoscopic cholecystectomy.

Preoperative Phase
Premedication
Midazolam, 1-2 mg IV, to reduce anxiety
Albuterol, two puffs, to prevent bronchospasm

Intraoperative Phase
Vascular access and monitoring
Vascular access: one peripheral IV catheter
Monitors: pulse oximetry, capnography, electrocardiogram, non-invasive blood pressure with standard adult cuff size, temperature
Induction
Propofol, 2 mg/kg IV (may precede with lidocaine, 1.5 mg/kg IV)
Neuromuscular blocking drug to facilitate tracheal intubation (succinylcholine, 1-2 mg/kg IV) or nondepolarizing neuromuscular-blocking drugs (rocuronium, 0.6 mg/kg)
Airway management
Facemask: adult medium size
Direct laryngoscopy: Macintosh 3 blade, 7.0-ID endotracheal tube
Maintenance
Inhaled aesthetic: sevoflurane or desflurane
Opioid-fentanyl: anticipate 2-4 mg/kg IV total during case
Neuromuscular blocking drug titrated to train-of-four monitor (peripheral nerve stimulator) at the ulnar nerve*
Emergence
Antagonize effects of nondepolarizing neuromuscular blocking drug: neostigmine, 70 mg/kg, and glycopyrrolate, 14 mg/kg IV, titrated to train-of-four monitor
Antiemetic: dexamethasone, 4 mg IV, at start of case; ondansetron, 4 mg IV, at end of case
Tracheal extubation: when patient is awake, breathing, and following commands
Possible intraoperative problem and approach
Bronchospasm: increase inspired oxygen and inhaled aesthetic concentrations, decrease surgical stimulation if possible, administer albuterol through endotracheal tube (5-10 puffs), adjust ventilator to maximize expiratory flow

Postoperative Phase
Postoperative pain control: patient-controlled analgesia – hydromorphone, 0.2 mg IV; 6-minute lock-out, no basal rate
Disposition: postanesthesia care unit, then hospital ward*Nondepolarizing neuromuscular blocking drug choices include rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium.

*Nondepolarizing neuromuscular blocking drug choices include rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium.

Source : Ronald DM & Manuel CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA

Do take note that sometime the anaesthesia plan may require modification of the plan which may include a specific requirement for an individual patient and thus may have implications for preparing additional equipment in the operating room for example, special equipment that may be kept in a cart dedicated to difficult airway management or in another instance, the patient’s responses to anaesthesia and surgery may also cause the anaesthesia plan to be adjusted.

When each patient’s anaesthesia care is planned and documented in the patient’s record, then you can be sure that medical record fully meets the two requirements of JCI Standard ASC.5

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

Ronald, DM & Manuel, CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA