Here is a graphic to show a summary of the periodicity of reassessments in 13 situations which can be found in a medical record. Click the image to view a larger image in a new tab of your current window.
Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware of the evidence of reassessment of all patients and results which are always entered in patients’ medical records. The results of these reassessments noted in the patient’s medical record is for the information and use of all those caring for the patient.
Health care practitioners – predominately doctors and nurses are the ones who routinely conduct reassessment of patients in the following situations:
HIM / MR practitioners also need to be aware that a reassessment is integral to ongoing patient care i.e. it is a continuous process, and it is the key to understanding whether care decisions are appropriate and effective, and are normally carried out at intervals based on the patient’s condition and treatment to determine their response to treatment and to plan for continued treatment or discharge.
However, the periodicity of reassessment depends on the condition as well as a patient’s needs extending to the plan for continued treatment or discharge, or as defined in organisation policies and procedures as in the following situations:
As I researched for this post, I found that this is the NOT the last in the list of medical record documentation requirements I have found as required by the Joint Commission International (JCI) standards for documentation required in a medical record.
I will still need to discuss on these other medical record documentation requirements:
Nonetheless, any hospital’s medical record documentation, irrespective if the hospital had undergone the journey to JCI accreditation or is planning to do so, all of which will contain reassessment findings recorded in them, including that related to needs when patients are at the end of life.
So if you are practising at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then your hospital will need to fully comply with the JCI Standard AOP.2 which states that “All patients are reassessed at intervals based on their condition and treatment to determine their response to treatment and to plan for continued treatment or discharge.” Documentation of reassessment of patients in their medical records also satisfies the JCI Standard MCI.19.1, Measurement Element 5 requirement which states that “Patient clinical records contain adequate information to document the course and results of treatment.”.
References:
It is natural to think of the Public Relations (PR) department of a hospital when a hospital needs to deal with a community it serves to facilitate access to care and access to information about its patient care services. Thus, it is not surprising to pass the buck to a representative of the PR department of a hospital sitting in a Management Of Communication And Information (MCI) Committee to deal with, and in order to comply with the Joint Commission International (JCI) Standard MCI.1 which states “The organization communicates with its community to facilitate access to care and access to information about its patient care services.”
I think if you are a leader championing the JCI MCI standards, this leader must not merely delegate this MCI standard to the PR department representative to deal with, but must also nurture as teacher, mentor, colleague, and friend to guide and be responsible to coach in the implementation and compliance of this standard, thus to care for and encourage the growth or development of MCI standards for the hospital. In this scenario, it is important for this leader to be knowledgeable in PR by at least researching the subject matter and linking his or her literature reviews with this standard.
From my interactions with representatives of PR department of hospitals, they normally deal with the management of both internal and external communications. They told me they are responsible for promotions of the hospital and implementation of the hospital’s marketing programmes that are related to overall mission and vision of the hospital, also manage and improve the flow of information within the hospital and between the hospital and the community it serves. Public relations professionals also serve as liaisons to the community and work closely with other health partners in the locality in preventive health. The responsibilities of a PR person in a hospital setting includes writing and distributing news release, feature articles to the press, compiling press list, witting of newsletters, handling and maintaining a media information service, arranging press, radio and television interviews for management, preparing marketing plans for various programmes and create strategies in promotional and marketing efforts. In summary, the PR department is responsible for community relations, hospital publications, media relations special events and support for fundraising.
Since the measurable elements for this standard requires a hospital to (i) implement a communication strategy, (ii) provide information on its services, hours of operation, and the process to obtain care through mass media interventions, such as those delivered by leaflets, booklets, posters, billboards, newspapers, radio and television, and (iii) provide information on the quality of its services, “the quality of services as is always determined by certain attributes that they have or should have. The most important attributes health services should have, are accessibility and availability,usage facility, public’s acceptance and all these always in relation to their cost.” (Athina and Andriani, 2012, p. 205) which is provided to the public and to referral sources with defined communities and populations of interest, I personally think that the PR department in a hospital is best suited to manage and measure this standard based on what I have already said in the preceding paragraph.
With all what I wrote above and what I intend to say in the next paragraph, let me remind you that all of us serving in the socioeconomic system of healthcare, including doctors and patients carry on our lives as person-systems within a hierarchy of multiple and overlapping systems of family, community and wider society. The internal needs of patients as person-systems, i.e. the patient is unwell, the patient’s family, workmates, employers and hospitals will tend to accept the sick role of this patient. After a defined length of time, the patient seeks the professional endorsement of a doctor for a clinical transaction, which is a subsystem of the hierarchy of systems comprising health care. At the end of the day, the person-systems of doctor and patient constituting of the patient, members of family, community systems and professional (e.g. the doctor) or economic systems, all support a speedy and complete return to health for the patient.
Members of the MCI Committee must be aware that the approach it chooses in understanding and measuring as well as complying with this standard, is driven by the care delivery for the population served by the hospital in advising patients on how to leverage the system to ensure coordination of care across the continuum, integrated across the continuum among defined communities and populations of interest with healthcare specialists in the hospital.
So what is this “defined communities and populations of interest”, if you are a member of a MCI Committee, you need to focus on?
Marie and Sandra (2011, pp. 46-47) define population of interest as “a population at risk or those with a common risk factor leading to the threat of a particular health issue. It also may be defined as a population of interest known as a healthy population who may in fact improve their health by making certain choices that will further promote health and/or protect against disease or injury. For example, an adolescent population that engages in alternative sports and chooses to wear protective gear avoids serious injury.”
I have been asked how and what does the PR department do in order to understand patterns and trends within this population of interest. First, I think it is the best interest of the PR department to be comfortable enough with information technology to collect and organise data, initiate and develop appropriate databases for their practice to better assess and serve the population of interest. I also think the PR department must design cross-sectional studies at finding out the prevalence of a phenomenon, problem, attitude or issue by taking a snap-shot or cross-section of the population. Pre-test/post-test studies could also be undertaken to measure the efficacy of a program on the same population to determine if a change has occurred.
I have also been asked how and what does the PR department do when identifying defined communities. My advice is that the PR department must be involved in gathering census data that provide the PR department with evidence about the overall health status of the population living in a particular community. The PR department could use the Internet which provides a wealth of data such as geography and history of a community as well as census track boundaries and data.
Armed with knowledge on defined communities and populations of interest, the PR department must surely be able to show evidence that there is (i) a communication strategy to reach the defined communities and populations of interest , (ii) information on its services, hours of operation, and the process to obtain care, and (iii) information on the quality of its services, which is provided to the public and to referral sources with defined communities and populations of interest, in order to fully comply with Standard MCI.1.
All this is possible when the hospital and the PR department jointly develop and revise strategic and operational plans to address community needs for a healthier community within larger geographic or political areas as reflected in the hospital’s mission and required by the JCI Standard GLD.3.1 which states that “Organization leaders plan with community leaders and leaders of other organizations to meet the community’s health care needs.”, thus recognising that they have responsibility for and can achieve an impact on the community.
References:
The attending doctor is responsible for a patient’s care and determines the patient’s readiness for discharge based on the policies and relevant criteria or indications of referral and discharge established by the hospital policy guiding the referral or discharge of patients .
Referring or discharging a patient to a health care practitioner outside the hospital, another care setting, home, or family is based on the patient’s health status and need for continuing care or services.
Continuity of care requires special preparation and considerations for some patients, such as for discharge planning.
Discharge Planning is a process which is initiated as soon as possible upon inpatient admission, that is during the initial assessment which includes determining the need for patients for whom discharge planning is critical due to age, lack of mobility, continuing medical and nursing needs, or assistance with activities of daily living, among others.
The discharge planning process includes a mechanism to identify those patients for whom discharge planning is critical. A discharge planning worksheet is generated based on a list of criteria and used as an assessment tool by a case manager or an utilisation manager (if there is one at your hospital, or in most instances initiated by a nurse), to identify patients who may require post-hospital services on discharge for inpatients once their acute phase of illness has passed. This worksheet is used to develop the Case Management Note which is a progress note documented by the case manager or an utilisation manager (if there is one at your hospital, or in most instances by a nurse),which outlines a discharge plan that includes case management/social services provided and patient education.
Discharge planning involves discussions on discharge plans with patients and their families on admission and during the hospital stay. A discharge plan is prepared to help determine home needs, assist in planning for needed medical equipment, helps in choosing a facility for care if the patient is unable to return home, and facilitates discharge to home or transfer to another facility.
The Case Management Note is not the same document as the Discharge Note which is the final progress note documented by the attending doctor, which includes details like the patient’s discharge destination (e.g., home), discharge medications, activity level allowed, and follow-up plan (e.g., office appointment).
Health Information Management (HIM) / Medical Records (MR) practitioners do take note that Health Information Management / Medical Records Management services does not include Discharge Planning. However HIM / MR practitioners can expect to find a Case Management Note included in some patients’ medical records.
HIM / MR practitioners who are members of a closed Medical Record Review, need to be aware that the Medical Record Review Tool will assess and determine the degree of compliance with standards and elements of performance relating to discharge planning given to some patients as required by the Joint Commission International (JCI) Standard AOP.1,11 which states that “The initial assessment includes determining the need for discharge planning.”, if you are working at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.
I like to point out that the Medical Record Review Tool has an error that shows the JCI Standard AOP.1.8.1 (Early screening for discharge planning) as found in the JCI Hospital Survey Process Guide, 3rd Edition, Effective January 2008 instead of showing the JCI Standard AOP.1,11 with regards to compliance in discharge planning. You can find my corrected version of this JCI recommended Medical Record Review Tool from this link (the form will open in a new tab of your current window).
References:
In order to compare its performance and to identify opportunities for improvement, a Hospital needs a mechanism for comparing its performance to that of other similar hospitals locally, nationally, and internationally with recognised, internationally accepted standards.
The mechanism must be designed to transform input forces and movement by (i) operate or interact by participating in external performance databases, (ii) compare its performance to that of other similar hospitals, into a desired set of output forces and movement when the hospital can identify opportunities for improvement and hence documenting its performance level.
This arrangement of connected parts in a system of parts of individual hospital performances like those parts of a machine is surely an effective tool to demonstrate the quality and safety that are being provided in the hospital and can be thought of as benchmarks of success when the hospital participates through reference databases.
I can think of the following initiatives in the US when hospitals as providers participate through reference databases to improve by benchmarking their performance against others, encourage private insurers and public programs to reward quality and efficiency, and help patients make informed choices:
In all instances, hospitals need to check if they are required by local laws or regulations to contribute to some external databases. Hospitals also need to maintain security and confidentiality of data and information at all times when operating or interacting with external databases.
ff your hospital is a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then the JCI Standard MCI.20.2 requires it to have a mechanism in place with the following characteristics:
References:
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