Category Archives: JCI Standards

Postings about medical documentation

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When I wrote “With this post, I believe I have covered postings about medical documentation found in a typical medical record and their relationship to the relevant JCI standards.” at the end of the post Collaboration, and the holistic care of the patient (this link will open in a new tab of your current window), I inadvertently missed out posting about the Standard COP.2.2 of the Joint Commission International (JCI) which is about “Those permitted to write patient orders write the order in the patient record in a uniform location”. and also about the Standard COP.2 which states “There is a process to integrate and to coordinate the care provided to each patient”. Actually the Standard COP.2 is linked with the standards I discussed under Collaboration, and the holistic care of the patient (this link will open in a new tab of your current window), i.e Standard AOP.4 and Standard AOP.4.1. I discussed Standard COP.2 under the post Process to integrate and to coordinate the care provided to each patient (this link will open in a new tab of your current window),

Since written patient orders as well as the results or conclusions of any patient care team meetings or other collaborative discussions written in the patient’s record are both medical documentation, I rushed to post about Standard COP.2 and Standard COP.2.2 in the post Process to integrate and to coordinate the care provided to each patient (this link will open in a new tab of your current window) and in the post Written patient orders (this link will open in a new tab of your current window)., respectively.

I think I can safely say now I have finally covered postings about medical documentation found in a typical medical record and their relationship to the relevant JCI standards.

Process to integrate and to coordinate the care provided to each patient

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The previous post Collaboration, and the holistic care of the patient (this link will open in a new tab of your current window), discussed collaboration between members of an interdisciplinary health care team in a hospital comprising of medical, nursing, and other individuals and services responsible for patient care when they use an interdisciplinary approach to analyse and to integrate patient assessments through which they identify the most urgent or important care needs for the patient.

Any results or conclusions from collaborative patient care team meetings or similar patient discussions reflecting this integration and coordination of care are written into the patient’s medical record showing each practitioner’s own observations and treatments.

If there is documentation in the medical record of patients as evidence of a process to integrate and to coordinate the care provided to each patient in the hospital, then this evidence meets the  Joint Commission International (JCI) requirement for the Standard COP.2 which states “There is a process to integrate and to coordinate the care provided to each patient”.

Integrating and coordinating care planning and care delivery among settings, departments, and services meets the JCI Standard COP.2 and the requirements ME1 and ME2. Documenting the results or conclusions of any patient care team meetings or other collaborative discussions in the patient’s medical record in turn meets the JCI Standard COP.2 requirement ME 3.

A Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital with JCI accreditation status or one that is seeking accreditation status, must know how the patient’s medical record facilitates and reflects the integration and coordination of care when each practitioner records observations and treatments in the patient’s medical record. Also, when any results or conclusions from collaborative patient care team meetings or similar patient discussions are written in the patient’s medical record.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Written patient orders

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Standard COP.2.2 of the Joint Commission International (JCI) is about “Those permitted to write patient orders write the order in the patient record in a uniform location”.

Image credit : http://ecowatch.org/wp-content/uploads/2012/05/drorders.jpg

Each patient care plan includes written orders by individuals qualified to order  and record patient orders, for example diagnostic tests orders for laboratory testing, orders for surgical and other procedures, medications orders, nursing care orders, and nutrition therapy orders.

A uniform location in the patient’s medical record or on a common order sheet which is then transferred to the patient’s medical record periodically or at discharge, facilitates understanding the specifics of an order, when the order is to be carried out, and who is to carry out the order as well as creates easy accessibility to the orders so that orders can be acted upon in a timely manner.

All the four (4) requirements (MEs) of the JCI Standard COP.2.2 will be fully met if the hospital staff are aware and practice what is contained in a hospital policy which among other policy statements also states policies on which orders must be written rather than verbal, which diagnostic imaging and clinical laboratory test orders must provide a clinical indication/rationale, if there any exceptions in specialised settings, such as emergency departments and intensive care units, the staff member who is permitted to write orders and where orders are to be located in the patient’s medical record.

Health Information Management (HIM) / Medical Records (MR) practitioners working in a hospital must be aware and knowledgeable that his or her medical records in his or her custody and care contain orders by individuals qualified to do so.

Orders will be found in all medical records regardless of the type of hospital they work at, whether or not his or her hospital had acquired JCI accreditation status or one that is seeking JCI accreditation status or it is one that is not seeking JCI accreditation status at all.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Collaboration, and the holistic care of the patient

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The Joint Commission International (JCI) has a set of two criteria regarding collaboration between members of an interdisciplinary health care team in a hospital which uses an interdisciplinary approach seeking or already with JCI hospital accreditation status. The first criterion is by meeting compliance with JCI Standard AOP.4  that requires “Medical, nursing, and other individuals and services responsible for patient care collaborate to analyze and to integrate patient assessments.” The second criterion is by meeting the JCI Standard AOP.4.1 when “The most urgent or important care needs are identified.”

A patient may undergo many kinds of assessments outside the hospital which include the community and third-party payers (both public and private reimbursement organisations, for example an insurance company or for example in Malaysia – SOCSO, the abbreviation for Social Security Organisation, and it is commonly known in the Malay term as PERKESO or Pertubuhan Keselamatan Sosial, a social security organisation which provides social security protection by social insurance including medical and cash benefits, provision of artificial aids and rehabilitation to Malaysian employees to reduce the sufferings and to provide financial guarantees and protection to the family), and inside the hospital by many different departments and services which includes hospital staff such as a doctor, a nurse, a dietitian, a social worker, and a physiotherapist in the care delivery of a patient that these health care providers must meet.

A collaborative process takes place during an initial assessment. This is a process during which patients are screened by nurses to identify those at nutritional risk, and is one kind of assessment used to plan, to deliver, and to monitor nutrition therapy.These patients are referred to a nutritionist for further assessment. When it is determined that a patient is at nutrition risk, a plan for nutrition therapy is carried out. The patient’s progress is monitored and recorded in his or her medical record. Doctors, nurses, the dietetics service, and, when appropriate, the patient’s family are seen collaborating to plan and to provide that nutrition therapy.

Collaboration to plan and to provide nutrition therapy as in the above example, clearly benefits such a patient most on the basis of recommendations by an interdisciplinary health care team by examining another’s viewpoint when the staff responsible for the patient work together (collaborate) to gather data, plan, implement, evaluate, and gain objectivity from the patient’s medical record. During this process, the most urgent or important care needs are identified, for example the need for nutrition therapy for a patient at nutrition risk. When patient assessment data and information are analysed and integrated, the JCI Standard AOP.4, ME 1 requirement is clearly met.

From such kinds of interdepartmental collaboration, the patient’s needs have been identified, the order of their importance established, and care decisions made. Integration of findings at this point will facilitate the coordination of care provision that helps ensure an efficient care processes, more effective use of human and other resources, the likelihood a beneficial (cost-effective) outcome and enhances quality and the holistic care of the patient.

The team approach satisfies the JCI Standard AOP.4, ME 2 requirement which requires “those responsible for the patient’s care participate in the process”. This is when health care providers from all the relevant disciplines are involved in a multidisciplinary evaluation which mandates active involvement of all the care providers in the evaluation of quality care. This participatory process of evaluation facilitates options and services for meeting the patient’s health and helps promote a continuum of care for the patient, from the preadmission phase to discharge planning and follow-up care.

The goal of the interdisciplinary health team during acute hospitalisation and rehabilitation is to restore function, thus maximising the level of the patient’s independence.

At the same time, health care providers are challenged to work in greater collaboration to decrease the client’s length of stay in the hospital, increase satisfaction with the services, and prevent complications.

It can be said that the majority of clinical transactions in hospital settings are routine and straightforward enough to warrant no special attention or modification to their management (Kingsley & Sam, 2009). Being faced with a complicated clinical transaction, and having to decide whether and how to intervene, require a methodical approach. An example of a complicated a clinical transaction maybe a patient presenting with physical illness may precipitate the relapse of psychiatric illnesses such as manic-depressive psychosis or schizophrenia.

This kind of complicated clinical transactions requires a dynamic and systematic collaborative approach in providing and coordinating for example, using tools and techniques to better integrate and to coordinate care for their patients through formal treatment team meetings, team-delivered care, multidepartmental patient conferences and clinical rounds, combined care planning forms, integrated patient record, and case managers.

The patient, families of the patient and others who make decisions on the patient’s behalf are not neglected in the care process but are duly informed of the planned care and treatment and participate in the decisions about the priority needs to be met.

For patients and families to participate in care decisions, they need basic information about the medical conditions found during assessment, including any confirmed diagnosis when appropriate, and on the proposed care and treatment. Although some patients may not wish to personally know a confirmed diagnosis or to participate in the decisions regarding their care, they are given the opportunity and can choose to participate through a family member, friend, or a surrogate decision maker.

Collaboration includes encouragement  to participate in family support groups through a family member, friend, or a surrogate decision maker in problem-solving activities in the decision process involving treatment and aftercare plans to promote continuity of care when it is needed. Such collaborative encouragement meets the requirements of ME 2 and ME3 of the JCI Standard AOP.4.1.

These actions to promote collaboration with the patient and his or her family and others when the patient’s needs are prioritised based on assessment results,  will comply with the requirement of the JCI Standard AOP.4.1, ME 1 and when the patient and family members are fully aware of the treatment process and outcomes, then the requirements of both ME 2 and ME3 of the JCI Standard AOP.4.1 are also clearly met.

A Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital with JCI accreditation status or one that is seeking accreditation status, must know how the patient’s medical record facilitates and reflects the integration and coordination of care when each practitioner records observations and treatments in the patient’s medical record. Also, when any results or conclusions from collaborative patient care team meetings or similar patient discussions are written in the patient’s medical record.

With this post, I believe I have covered postings about medical documentation found in a typical medical record and their relationship to the relevant JCI standards.

In my next post about medical documentation found in a typical medical record, I shall summarise and tabulate the  relevant JCI standards and their respective requirements, and move on to posting on the remainder of the surgical documentation found in a typical medical record, and their relationship to the relevant JCI standards.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Kingsley, N & Sam, S 2009, Problems with patients, Cambridge University Press, NY, USA

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

JCI Standard MCI.12 – a policy on the retention time of records, data, and information

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Paper-based medical records is the way most public and private hospitals in Malaysia continue to preserve their patient medical records. Existing filing space for the efficient storage of newer medical records is a common problem, and for most Health Information Management (HIM) / Medical Records (MR) practitioners, it is a never-ending battle against overcrowded files and the struggle to find more space.

The need for adequate storage space for newer and older medical records (as you already know, older medical records placed in storage and rarely accessed are called archived records or inactive records) is driven by medical reasons, legal reasons and management reasons.

Medical records must be kept for so long as they are necessary to support patient care in the treatment and management of cases.

The legal documentation reason has heightened the importance of medical record retention (the length of time a hospital for example will maintain an archived record ) from the threat of medical malpractice suits, as patient and their families become more aware of the rights to quality care, and solicitors ever willing to take on medical malpractice suits.

Thus, the medical records must be kept for so long as long as the threat of a medical malpractice suit exists. So if the medical records are necessary for the purpose of a court case, the medical records must be kept until the case is concluded, a process which may take many years. A doctor may be in court as a litigant or a witness. Even as a witness in a case which is heard many years after the events in question, the doctor may need to refer to the original medical records.

Collection of hospital statistics, disease coding, claims processing, communicable disease reporting, incident reporting, morbidity and mortality reviews are some management reasons.

Does this mean that, if at all possible, medical records should be maintained indefinitely?

Given the hospital’s administrative constrains to provide additional space with additional cost implied versus the statutory mandates to maintain medical records for a defined period for legal reasons, the medical reasons, and the management reasons,.a hospital needs a strategic plan for preserving medical records for a definite period of retention.

Image credit : silverdane.com

The hospital must develop a medical record retention policy and must be guided by its own activities, research and education activities.

This policy will dictate how medical records are to stored (records can be stored on paper, microfilm, magnetic tape, optical disk, or as part of an electronic (or computer) system), where will they be stored, what happens to the medical records that have lapsed the retention period , all of which are guided by statute, regulation, law and guidelines.

I shall refrain from posting the methods of storage of newer and older medical records and the destruction of medical records that have lapsed the retention period, as I intend to only discuss on establishing a hospital retention policy for medical reasons and legal reasons but briefly and discuss a little more the quality assurance reasons.

HIM/MR practitioners already know that medical records serve for the continuity of medical and nursing care while in hospital, and follow-up care. HIM/MR practitioners also know that medical records must be maintained for specific periods for legal reasons and I like to list the relevant statutes, laws and guidelines that prevail in Malaysia :

  1. The statute of limitations, Act 254, cited as the Limitation Act 1953, dated 19 February 1953, is an Act to provide for the limitation of actions and arbitrations (which is the time period during which a person may bring forth a lawsuit including medical malpractice suits), but applies to Peninsular Malaysia only.
      1. Section 6(1) of this Act limits actions in tort to commence not more than six years after the occurrence of the damage and unlike laws in Australia, the United Kingdom and in Singapore, does not contain provisions for the discretionary extension or exclusion of the time limit allowed by law in relation to tort or personal injuries.
      2. Include in the policy if patient is under a legal disability, that the records should be kept for a minimum of 7 years from the date when the patient’s legal disability ceases or the patient’s death, whichever is earlier, as provided for under Section 24(1) of this act.
  2. Act 629, the National Archives Act 2003 (incorporating all amendments up to 1 January 2006), is an Act to provide for the creation, acquisition, custody, preservation, use and management of public archives and public records (records officially received or produced by any public office for the conduct of its affairs or by any public officer or employee of a public office in the course of his official duties and includes the records of any Government enterprise) and for other matters connected therewith.
      1. The National Archives of Malaysia had supported and agreed to a Ministry of Health Malaysia proposal for a uniform medical records retention and disposal schedule for all public hospitals in Malaysia. Through its letter of approval allowable under Section 27 (1) of the Act 629, the National Archives Act 2003, an approval dated 30 November 2006 was released by the National Archives for a comprehensive and standarised medical records retention and disposal schedule for all public hospitals and health facilities in Malaysia.
      2. The retention period for all medical records with the exception of medical records of psychiatric, obstetric and paediatric cases will be retained for a period of seven (7) years from the last date of treatment.
      3. A copy of this approval can be obtained from a Ministry of Health Malaysia Guideline Manual on Medical Records Management published by the Medical Development Division and released through a Director General of Health Malaysia directive No. 17 of 2012 (Pekeliling Ketua Pengarah Kesihatan Bil 17/2010, Garispanduan Pengendalian Dan Pengurusan Rekod Perubatan Pesakit Bagi Hospital-Hospital Dan Institusi Perubatan Kementerian Kesihatan Malaysia, Bahagian Perkembangan Perubatan Kementerian Kesihatan Malaysia, a document in Malay).
      4. The standarised medical records retention and disposal schedule for all public hospitals and health facilities in Malaysia was circulated through a MoH circular MOH/PAK/121.06.(GU), Mac 2007 in March 2007(Jadual Pelupusan Rekod Perubatan, MOH/PAK/121.06.(GU), Mac 2007 – in Malay).
  3. Act 586, Private Healthcare Facilities And Services Act 1998 (incorporating all amendments up to 1 May 2006) is an Act to provide for the regulation and control of private healthcare facilities and services and other health-related facilities and services. Section 107, (2), (f) under ‘Power to make regulations’ requires that the records to be kept of patients and persons treated in the private healthcare facilities or services but does not stipulate a retention policy.
      1. I think such private healthcare facilities or services could however plan for a retention policy for the reasons given in second paragraph of this post.
      2. The same provision of a minimum period of seven (7) years from the last date of treatment for the retention of all medical records with the exception of medical records of psychiatric, obstetric and paediatric cases could b adopted into a private hospital’s retention policy.
      3. Likewise other contents of the medical records retention and disposal schedule for all public hospitals and health facilities in Malaysia could be availed and incorporated into its own private hospital medical records retention policy.
  4. Act 21, this Act cited as the Age of Majority Act 1971 dated 30 April 1971 is an Act to amend and consolidate the law relating to the age of, states under Section (2) that the minority of all males and females shall cease and determine within Malaysia at the age of eighteen years and every such male and female attaining that age shall be of the age of majority.
      1. Since the minimum period for the retention of all medical records with the exception of medical records of psychiatric, obstetric and paediatric cases is seven (7) years from the last date of treatment, then for minors medical records should be retained for another 7 years from the age of majority, that is for 25 years.
  5. The Medical Defence Malaysia Berhad (MDMB) website at http://www.mdm.org.my/articles.php?newsID=2 (clicking on this link will open the website page in a new tab in your current window) presents a page on Medical Records: Preservation And Matters Of Evidence.  MDMB a “not-for-profit” company limited by guarantee, functioning as a mutual medical defence organisation that aims to provide support in areas such as medico-legal counselling and the development of educational resources.

HIM/MR practitioners must also know that if their hospital is in the process for accreditation of a quality program, then the medical records retention policy must be updated, readily available, complete and relevant. In order to be complete and relevant, I would recommend that this policy be jointly developed with the full knowledge and participation of the medical staff  who have contributed to a medical record content.

HIM/MR practitioners would provide secretarial support, coordinate the updating and completion of a up-to-date and revised hospital medical records policy. This policy will be measured against the Joint Commission International (JCI) Standard MCI.12 which states that “The organization has a policy on the retention time of records, data, and information”, if your hospital is on the path to be accredited or is to be re-surveyed for new period of accredited status when adopting the JCI accreditation process.

So if your hospital has a policy on retaining medical (patient clinical) records and other data and information, the retention process provides expected confidentiality and security, and all of your records, data, and information are destroyed appropriately after the retention period, then clearly this policy will comply with the JCI Standard MCI.12, ME 1 to ME 3.

This is not to imply you only rush to comply with JCI compliance (the JCI Standard MCI.12 merely states this requirement to comply with their standards compliance and accreditation status but does not necessarily mandate record retention schedules) but the policy is relevant for all the reasons as I have given above, once again to reiterate federal and local (if any) retention laws, legal requirements, need for continuing patient care and follow-up, research/educational uses, and management uses.

In closing, do take note that a  policy on retention of medical records is meant to serve as a guide on the retention periods for medical records, and do get the help of a legal counsel of your hospital or organisation if you are not sure about the Laws and their interpretations to be included in the policy.

References:
Edna,  KF 1983, Medical Records Management, 7th edn, Physician Records Company, Illiniois, USA

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Margaret, AS 2003, Health Information Management, 5th edn, Jossey-Bass, San Framsico, USA

World Health Organisation 2006, Medical Records Manual: A Guide for Developing Countries, WHO Regional Office for the Western Pacific, Philippines