Category Archives: JCI Standards

End-of-life issues, what you need to document in the medical record

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Image credit : National Institutes of Health, USA

Image credit : National Institutes of Health, USA

Assessment findings guide the care and services to be provided by all the patient’s health care practitioners, including the doctor and/or nurse. The findings are then normally documented in the patient’s medical record.

Likewise, reassessment by a doctor are also documented in the patient’s medical record. I had posted about the need to document reassessment into the patient’s medical record as defined in organisation policies and procedures for thirteen (13) situations in the post Reassessment of all patients and results are always entered in their medical records (this link will open in a new tab of your current browser window), the thirteenth situation been when dying patients and their families are assessed and reassessed according to their individualised needs by evaluating and managing their symptoms and preventing complications to the extent reasonably possible in the care of these dying patient to optimize his or her comfort and dignity.

When patients are at the end of life, these dying patients including their families or indeed anyone else actually connected with the patient are then assessed and reassessed to identify the patients’ and families’ needs, i.e end-of-life issues. Assessments and reassessment are carried out to evaluate the patient’s condition such as symptoms of nausea and respiratory distress and to identify factors that seem to alleviate or exacerbate the physical symptoms, the patient’s current symptom management and the patient’s response.

Thus the medical record of a dying patient should contain documentation on symptoms like nausea and respiratory distress and whatever factors that are alleviating or exacerbating these physical symptoms.

Also to be found in the medical record of a dying patient will be documentation on assessments on both the patient’s and family’s individualised needs including evaluations to record the following :

  1. spirituality – it would be much more difficult to anticipate the spiritual needs of a patient and family from a culture unfamiliar to you, so better understand what is the patient’s and the surrounding family members’ dominant religion and views regarding the meaning and purpose of life and, as appropriate, any involvement to a religious group and what are their spiritual concerns or needs, such as despair, suffering, guilt, or forgiveness, thus the need to work within the patient’s and the patient’s family cultural belief system by hearing the patient and his or her family and the patient’s daily experiences; culturally based care i.e transcultural nursing according to Madeleine Leininger who was a nursing theorist, nursing professor and developer of the concept of transcultural nursing, contributes to healing (health), well-being, and helping patients who face dying or death
  2. their psychosocial status, such as family relationships, the adequacy of the home environment if care is provided there, coping mechanisms
  3. the patient’s and family’s reactions to illness since the patient will experience significant loss as a result of the health alteration when recovery from illness is incomplete; as a result many people (patient and/or family) may direct that anger towards health-care personnel because they have no control over the situation already as the loss begins to sink in but when finally, the patient and family come to terms with the loss, they will begin making plans for the future
  4. the need for support or respite services with the challenges of caring for the dying by the caregiver(s)
  5. the patient’s need or request from the patient’s family for, an alternative setting or level of care
  6. any survivor risk factors, such as family coping mechanisms and the potential for pathological grief reaction

The above documentation requirements in a medical record of a dying patient are required more so if you as a Health Information Management (HIM) / Medical Records (MR) practitioner manage such medical records in a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, when your hospital will need to fully comply with the JCI Standard AOP.1.9 which states that “Dying patients and their families are assessed and reassessed according to their individualized needs.” The three (3) Measurable Elements of Standard AOP.1.9 will be measured through the Medical Record Review Tool (MMRT).

Medical records documentation of dying patients is not just to comply with an accreditation body like the JCI.  The filing of the medical record about end-of-life concerns about the amount of information which might be submitted within the medical record which will then be subject to scrutiny irrespective of whether that scrutiny included any authorised investigatory agency. Although a doctor may believe  that he or she may not have done nothing wrong, he or she will fear the process of investigation of deaths (Stephen 2012), under a death reporting system.

As a diversion to end-of-life issues, medical records of a not-dying patient, Hilly Boscher from the Netherlands is worthy of mention when in the Chabot case (Stephen 2012), a psychiatrist named Chabot helped this patient to die who was NOT terminally ill i.e NOT a dying patient. In this case, she (Hilly) had been suffering from grief as a result of losing both of her children. Dr Chabot diagnosis was :  ‘an adjustment disorder consisting of a depressed mood, without psychotic signs, in the context of a complicated bereavement process’. Hilly had refused all anti-depressants and bereavement counselling. However, Chabot was not convicted by the Dutch Supreme Court on the ground that (Stephen 2012 p.288) “there was no requirement that suffering is terminal or physical”.  My point is, seven (7) other psychiatrists had examined her medical records and had agreed with Chabot’s diagnosis, so do you agree that there is the greater need for greater detail in medical records documentation in the case of a dying patient?

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA
  3. Stephen, WS 2012, End-of-Life Decisions in Medical Care Principles and Policies for 
  4. Regulating the Dying Process, Cambridge University Press, Cambridge, United Kingdom
  5. Pamela, MS & Linda, N 2010, Communication for nurses : how to prevent harmful events and promote patient safety, F. A. Davis Company, Philadelphia, PA, USA

JCI Standard MCI.8 – Patient transfers within a hospital

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Patients may be transferred within the hospital during their care or to other settings outside of the hospital based on status and the need to meet their continuing care.

Let us consider the case of a patient who is transferred within the hospital. In this instance, the care team changes and so essential information related to the patient needs to be transferred with him or her to facilitate continuity of care for this patient. Thus, medications and other treatments for this patient can continue uninterrupted, and the patient’s status can be appropriately monitored.

What Health Information Management (HIM) / Medical Records (MR) practitioners need to know is in order to accomplish this information transfer when a patient is transferred within the hospital., the patient’s medical record(s) is transferred or information from the patient’s medical record is summarised at transfer as shown in the graphics below. If you work at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then this specific requirement is as stated for JCI MCI.8 which states that “Information related to the patient’s care is transferred with the patient.”

Patient-transfer-summary-MCI,8-clipboard

Another point to take note by the general reader is when a patient is transferred to other settings outside the hospital, the transfer process is documented in the patient’s medical record including documentation of any change in patient condition or status during transfer just as in the case for a patient transferred within the hospital, as I had posted in the post 5 transfer process entries that must be entered in a medical record (this link will open in a new tab of your current browser window).

I like to conclude that I think it is appropriate for  HIM / MR practitioners who work at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, to take note that transfers within a hospital or to outside the hospital is covered by 1 standard under the Management of Communication and Information (MCI) chapter and by 5 JCI standards under the Access to Care and Continuity of Care (ACC) chapter respectively from the JCI Accreditation Standards For Hospitals, 4th Edition.

References:

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

Must medical records show evidence of specialised assessments?

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Let’s look at a simplified diagnostic process from the diagram below, when hearing, visual and dental tests are three common screening tests during the initial assessment during the review of the complaint, history and physical when the patient arrives with complaint at a hospital.

Simplified Diagnostic Process

Diagram credit: Kenneth, RW & John, RG 2010, The well-managed healthcare organization, 7th edn, Health Administration Press, Chicago, Illinois, USA

Auditory testing performed during an initial assessment is usually done with a tuning fork. Tests using a tuning fork are meant for screening only and never used for diagnostic purpose. Auditory testing provides the examiner during initial assessment with a basic idea of whether the patient has for example, a hearing loss. Thus, such a test simply provides an indication of the need for more elaborate testing and referral to a hearing specialist for more accurate testing if a problem is suspected.

Assessment of vision examines both visual acuity and anatomic structures. If you wear glasses, you had your visual acuity tested with the Snellen chart, a chart that contains various-sized letters with standardised numbers at the end of each line of letters. Visual acuity of 20/20 is considered normal. Astigmatism, hyperopia (farsightedness), myopia (nearsightedness) and presbyopia (farsightedness) are common vision related conditions. Assessment of eye structures and function present significant findings and possible causes for condtions like nystagmus and cataracts.

Another initial assessment is the assessment of the mouth, throat, nose, and sinuses which usually follows the examination of the head and neck. Examination of the mouth and throat can help detect abnormalities, for example of the lips. Early detection of oral cancer during an oral examination is an important finding. A deviated septum or detection of sinus infection are two other conditions that maybe detected during this kind of examination. Overall, the patient’s nutritional and respiratory status is also assessed.

From the diagram above, treatment is usually begun once the diagnosis is confirmed by the attending doctor, the initial caregiver. Sometimes, the initial assessment process may identify a need for other assessments.  Thus, patients maybe referred and/or discharged based on their health status and needs for continuing care by other specialised health care providers to support their continuing continued care and learning needs. Patients are referred within the hospital or discharged from the hospital to a health care practitioner outside the hospital, another care setting, home, or family when the additional specialised assessment is identified during the initial assessment.

Health Information Management (HIM) / Medical Records (MR) practitioners must take note that specialised assessments conducted within the hospital should be documented in the patient’s medical record. Medical records documentation must show evidence of specialised assessments conducted within the hospital, especially so if you work at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, when the JCI Standard AOP.1.10 which states that “The initial assessment includes determining the need for additional specialized assessments.” requires complete documentation in the patient’s medical record of the need for additional specialised assessments conducted within the hospital.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Kenneth, RW & John, RG 2010, The well-managed healthcare organization, 7th edn, Health Administration Press, Chicago, Illinois, USA
  3. Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Medical Records and the continuum of care

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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:

  1. 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”
  2. 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
  3. 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)
  4. 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
  5. be aware that the JCI Standard ACC.2.1 is included in the Medical Records Review Tool

References:

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

Wait times documentation in the medical record

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Cartoon credit: theragblog.blogspot.com/

Cartoon credit: theragblog.blogspot.com/

Health Information Management (HIM) / Medical Records (MR) practitioners maybe unaware of information documented in the patient’s medical record when inpatients and outpatients seeking care and/or diagnostic services patients, undergo long waiting periods for diagnostic and/or treatment services or when obtaining the planned care may require placement on a waiting list.

The issue of waiting periods for healthcare may be described from the study by Singh et al. (2010) as patient-related i.e delays referring to the time period from the onset of symptoms to the patient’s seeking of medical advice or health system-related. Singh et al. (2010) define health system delays to the time period from the first contact of the patient with the health care system to definitive treatment, which may also include delays in patient access to first contact. Singh et al (2010) further categorised health system delays into diagnostic delays defined as time from the patient’s first contact with the health care system to diagnosis and treatment delays as time from diagnosis to definitive treatment.

HIM / MR practitioners practising at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, must be aware that the JCI Standard ACC.1.1.3 which states that “The organization considers the clinical needs of patients when there are waiting periods or delays for diagnostic and/or treatment services.” which requires the aforesaid reasons and alternatives on waiting periods to be duly documented in the patient’s medical record and this requirement applies to:

  1. inpatient and outpatient care and/or diagnostic services
  2. does not include minor waits in providing outpatient care or inpatient care, such as when a doctor is behind schedule
  3. does not apply for oncology cases or transplant cases 

To this end, HIM / MR practitioners must:

  1. be able to locate information recorded in the patient’s medical record that will contain the associated reasons for the delay or wait and available alternatives consistent with their clinical needs;
  2. must be aware that the JCI Standard ACC.1.1.3 is included in the Medical Records Review Tool; and
  3. include this requirement in HIM / MR written policies and/or procedures to support consistent practice.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Singh, H, Coster, DC, Shu, E,  Fradette, K, Latosinksy, S, Pitz, M, Cheang, M & Turner, D 2010, Wait times from presentation to treatment for colorectal cancer: A population-based study, Canadian Journal of Gastroenterology, vol. 24, no. 1, pp. 33–39, viewed 2 July 2013, < http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2830632/#__ffn_sectitle>