Category Archives: JCI

Written surgical report

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In Malaysia, in most instances Health Information Management (HIM) /
Medical Records (MR) practitioners may only find the postoperative note documented in the medical record. The postoperative note is an operative or other high-risk procedure report documented by the surgeon after surgery in the postoperative phase. This after surgery phase is when the client leaves the Operating Room (OR) and is taken to a Post-Anaesthesia Care Unit (PACU) and continues until the patient is discharged from the care of the surgeon upon completion of the operative or other high-risk procedure and before the patient is transferred to the next level of care.

In addition to the postoperative note, a surgeon may also dictate an operative record in hospitals where dictation services are available, in Malaysia or in other countries.Some hospitals may create special forms to facilitate an operative record documentation.

Thus, it is common to find a comprehensive operative progress note documented by the surgeon written in the progress notes in the patient medical record. However, a HIM/MR practitioner may also find that the patient medical record often contains as well as a transcribed operative record. Both of this documentation is authenticated by the responsible surgeon.

HIM/MR practitioners must not be confused between postoperative evaluations documented by the surgeon with postanaesthesia evaluations documented by the anaesthesiologists.

The content for the postoperative progress notes and/or operative record will normally contain documentation as follows:

  1. patient’s vital signs and level of consciousness
  2. any medications, including intravenous fluids, administered blood, blood products, and blood components
  3. any unanticipated events or complications (including estimated blood loss and blood transfusion reactions) and the management of those events, or the absence of complications during the procedure
  4. name of the procedure and techniques associated with the performance of surgery
  5. description of other procedures performed during operative episode
  6. description of gross operative findings, including organs explored
  7. postoperative diagnosis
  8. name of operative surgeon and assistants
  9. surgical specimens sent for examination
  10. documentation of ligatures, sutures, number of packs, drains, and sponges used
  11. date, time, and signature of responsible surgeon

If your hospital is seeking a hospital accreditation status for example the Joint Commission International (JCI) accreditation status or already JCI accredited or plans for a JCI re-survey, then it is only normal to comply with the JCI Standard ASC.7.2  which requires :

(i) that there is a surgical report or a brief operative note (which may be used in lieu of the written surgical report) available prior to the patient leaving the postanesthesia recovery area to support a continuum of postsurgical supportive care, thus meeting Measurable Element (ME) 2 compliance for this standard, and

(ii) that the surgical report or a brief operative note is documented with at least the minimum six (6) elements as required by JCI Standard ASC.7.2, ME 1 (which I have already included in the list above) for the written surgical report or brief operative note in the patient’s medical record.

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

The postanesthesia recovery period

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The postoperative period is the last phase after the preoperative and intraoperative phases of the perioperative phases, when anaesthesia providers care for the surgical patient by assessing the patient after recovery from anaesthesia.

During the postoperative period, patients are recovering from anaesthesia and surgery.  In a tertiary care hospital, the postanaesthesia care unit (PACU) is staffed to monitor and care for patients who are recovering from the immediate physiologic effects of anaesthesia and surgery during this postanaesthesia recovery period.

Patients in the PACU are monitored according to a hospital policy stating the standards for postanaesthesia care during the postanaesthesia recovery period intended to encourage quality patient care. A hospital policy stating the standards for post anaesthesia care will apply to postanaesthesia care in all locations (Ronald and Manuel, 2011).

Recording of monitoring data according to standards and anaesthesia practice parameters, provides the documentation to support discharge decisions.

The ongoing, systematic collection and analysis of data on the patient’s status in recovery in the PACU support decisions during this unique transition period, about moving the patient from delivery of anaesthesia in the operating room to the less acute monitoring on the hospital ward and, in some cases, independent function of the patient at home.

Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware that monitoring findings are entered into the patient’s medical record by written or electronic entry.

Patients are discharged from the PACU (or recovery monitoring is discontinued) by one of the following specific PACU discharge criteria (JCI, 2011) using discharge scoring systems which may vary in your hospital but certain general principles are universally applicable (Ronald and Manuel, 2011) :

  1. “the patient is discharged (or recovery monitoring is discontinued) by a fully qualified anaesthesiologist or other individual authorised by the individual(s) responsible for managing the anaesthesia services” (JCI, 2011), and who accepts responsibility for discharge of patients from the PACU
  2. “the patient is discharged (or recovery monitoring is discontinued) by a nurse or similarly qualified individual in accordance with postanaesthesia criteria developed by the hospital’s management, and the patient’s record contains evidence that criteria are met” (JCI, 2011)
  3. “the patient is discharged to a unit which is capable of providing postanaesthesia or postsedation care of selected patients, such as a cardiovascular intensive care unit or neurosurgical intensive care unit, among others” (JCI, 2011)

HIM/MR practitioners also need to be aware that the time of arrival and discharge from the recovery area (or discontinuation of recovery monitoring) is recorded.

If your hospital is undergoing a hospital accrediation process from for example by the Joint Commission International (JCI), then documentation of postanaesthesia care is measured through JCI Standard ASC.6 which states that “Each patient’s postanaesthesia status is monitored and documented, and the patient is discharged from the recovery area by a qualified individual or by using established criteria.” For hospitals  undergoing a hospital accreditation process or re-applying for accreditation status by the JCI, then JCI Standard ASC.6 and its three (3) Measurable Elements (MEs) that measure postanaesthesia care must be fully met during the survey process.

With this background about the postoperative period when anaesthesia providers care for the surgical patient by reassessing the patient after recovery from anaesthesia in a PACU of any tertiary care hospital, and the requirement of a hospital accreditation standard like that of the JCI Standard ASC.6, the HIM/MR practitioner’s role with regards to postanaesthesia documentation in the medical record would be to verify if the medical record contents for a patient include, (i) a postanaesthesia evaluation note, which is a progress note documented by any individual qualified to administer anaesthesia in the an the appropriate section of a common pre- and postanaesthesia evaluation note, and (ii) a separate recovery room record.

A postanaesthesia evaluation note (Michelle and Mary, 2011) includes :

  1. “patient’s general condition following surgery”
  2. “description of presence/absence of anaesthesia-related complications and/or postoperative abnormalities”
  3. “blood pressure, pulse, presence/absence of swallowing reflex and cyanosis”

After the completion of surgery, patients are taken to the recovery room where the anaesthesiologist and recovery room nurse are responsible for documenting a PACU or recovery room record.

Postoperative documentation – the recovery room record, regarding the discharge of the patient from the postsedation or postanaesthesia care area (e.g., recovery room) adapted from Michelle and Mary (2011) includes :

  1. “patient’s general condition upon arrival to recovery room”
  2. “postoperative/postanaesthesia care given”
  3. “patient’s level of consciousness upon entering and leaving the recovery room”
  4. “description of presence/absence of anaesthesia related complications and/or postoperative”
  5. “abnormalities (may be documented in progress notes)”
  6. “monitoring of patient vital signs, including blood pressure, pulse, and presence/absence of swallowing reflex and cyanosis”
  7. “documentation of infusions, surgical dressings, tubes, catheters, and drains”
  8. “written order dated, timed  and authenticated for example by the anaesthesiologist releasing patient from recovery room” is documented in the surgeon’s orders according to hospital policy stating the standards for post anaesthesia care
  9. “documentation of transfer to nursing unit or discharge home”, also according to hospital policy stating the standards for post anaesthesia care

HIM/MR practitioners, do take note that anaesthesiologists sometimes document the postanaesthesia evaluation progress notes on a special form located on the reverse side of the anaesthesia record, so  no documentation elements are forgotten.

Here is a graphic of the types of anaesthesia care documentation found in the medical record for any surgical patient when anaesthesia providers care for the surgical patient through the preoperative, postoperative, and intraoperative phases of the perioperative period (you can view a larger image by clicking on the image below which will open in a new tab of your current browser window).

I believe I have covered all the required surgical information documentation for anaesthesia care required in a medical record with this post on anaesthesia care

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.20 – Aggregate data and information support patient care, organisation management, and the quality management program

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Hospitals seeking accreditation status or planning for an accreditation re-survey process for example, accreditation status from the Joint Commission International (JCI), must ensure that their aggregate data and information supports patient care, organisation management, and their hospital quality management program.

Image credit : A representation of data found @ http://www.celframe.com/blogs/ by Jer Thorp, a data artist

Health Information Management (HIM) / Medical Records (MR) practitioners and their HIM/MR department in hospitals are responsible for aggregate data based on performance and utilisation by collecting, retrieving, compiling, calculating, analysing, and reporting descriptive health care statistics regarding for example admission, discharge, and length of stay of patients which are used internally by hospitals to describe the types and numbers of patients treated, that is patient-centric data which is directly related to the patient population treated.

The primary purpose of collecting patient-centric data is to provide factual numerical information using automated computer systems or manually.

HIM/MR practitioners play a vital role in collecting and verifying patient-centric data and are responsible for monitoring operations and overseeing the processes at their hospital which generate the patient-centric data. HIM/MR practitioners must accept that their role is most important as hospital statistics provide a benchmark upon which decisions are made to operate and manage the hospital.

The factual numerical information is used for clinical and management decisions making by summarising them into descriptive statistics.  Descriptive statistics summarise a set of data from the descriptive health care statistics and prepared into various presentation techniques and tools (e.g., bar graphs, pie charts, line diagrams, and so on) which help give meaning to statistics. In addition to reporting the number of patients treated, HIM/MR departments will also calculate rates and percentages of deaths, autopsies, infections, and so on.

Ongoing aggregate data and information related processes based on performance and utilisation that support patient care in a hospital, will meet the requirement of the JCI Standard MCI.20, ME 1.

It is common for hospitals to generate monthly and annual reports that describe the number of patients treated and the types of services delivered. This transformed-based data are used to prepare for example an annual report for the board of directors.  This report is used to make decisions that impact hospital operations and planning. Aggregate data and information used in this way to support organisation management, meets the requirement of the JCI Standard MCI.20, ME 2.

I shall end this post here and continue more on the JCI Standard MCI.20 in another post. I think the aspect of data quality is most important and deserves another post.

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

Check your medical record for patient monitoring during anaesthesia

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This saturday weekend evening, I finish a post on one of the six (6) standards for Anaesthesia Care found in the Joint Commission International Accreditation Standards For Hospitals, 4th Edition that requires documentation in the medical record. I have two (2) more remaining standards to write about under Anaesthesia Care. This post is about patient monitoring during anaesthesia.

The overall monitoring during anaesthesia is a continuous process (“continuous” meaning, prolonged without any interruption at any time) mandated by accreditation requirements for example, by the Joint Commission International (JCI) Standard ASC.5.3, as one of the JCI standards that guide the quality improvement program in anaesthesia that apply to all general anaesthetics, regional anaesthetics, and monitored anaesthesia care. JCI Standard ASC.5.3  evaluates the quality of care by attention to the process of monitoring of the patient during anaesthesia. Adequate monitoring is a key factor (Ronald & Manuel, 2011) in the prevention of patient injury related to anaesthesia

Monitoring and maintenance of normal physiology during the perioperioperative period of anaesthetised patients is designed to collect data that reflect the patient’s ongoing physiologic conditions and any responses that may result from therapeutic interventions. Monitoring allows the anaesthesiologist to react to adverse physiologic changes or trends before they result in irreversible damage. Monitoring is deemed (Ronald & Manuel, 2011) to serve to further enhance the vigilance of the anaesthesiologist and decrease the role of human error in anaesthetic morbidity and mortality.

Monitoring methods depend on the patient’s preanaesthesia status, anaesthesia choice, and complexity of the surgical or other procedure performed during anaesthesia.

The vigilance of the anaesthesiologist is enhanced by the use of a monitoring equipment such as the anaesthesia workstation (previously recognised as the anaesthesia machine) which has evolved (Ronald & Manuel, 2011) from a simple pneumatic device to a complex integrated computer controlled multicomponent workstation that includes physiologic monitoring systems (electrocardiogram, arterial blood pressure, temperature, pulse oximeter, and inhaled and exhaled concentrations of oxygen, carbon dioxide, anaesthetic gases, and vapors). The anaesthesia workstation provides objective data to the anaesthesiologist’s own subjective observations.

From my experiences, it is commonly viewed that anaesthesia standards are applicable in whatever setting anaesthesia and/or moderate or deep sedation are used because of the (JCI, 2011) common and complex processes of the administration of anaesthesia during which the patient’s protective reflexes needed for ventilatory functions are at risk.

In the prevention of patient injury related to anaesthesia,  JCI Standard ASC.5.3 or in all cases when the use of  (JCI, 2011) anaesthesia, sedation, and surgical interventions are common at settings which include hospital operating theatres, day surgery or day hospital units, dental and other outpatient clinics, emergency services, intensive care areas, or elsewhere must have a hospital policy and standard operating procedures which address the following issues for anaesthetised patients:

  1. the basic anaesthetic monitoring standards adopted for example from Standards for Basic Anaesthetic Monitoring  by the American Society of Anaesthesiologists, that mandate (Ronald & Manuel, 2011) the use of pulse oximetry, capnography, an oxygen analyzer, disconnect alarms, body temperature measurements, and a visual display of an electrocardiogram (ECG) during the intra-operative period in all patients undergoing anaesthesia.
  2. the minimum frequency, for example systemic blood pressure and heart rate must be evaluated every 5 minutes
  3. the choice of intra-operative monitoring during anaesthesia depends on the patient’s medical condition and the complexity of the intra-operative procedure
  4. the type of anaesthesia is uniform for similar patients receiving similar anaesthesia wherever anaesthesia is provided
  5. the patient’s physiological status assessed immediately after recovery from anaesthesia

The JCI Standard ASC.5.3 requires documentation of monitoring of the patient during administration of anaesthesia. An anaesthesia record is required and must be maintained when a patient receives an anaesthetic other than a local anaesthetic to document patient monitoring during administration of anaesthetic agents and other activities related to the surgical episode (intra-operative anesthesia).

Documentation regarding monitoring of the patient during administration of anaesthesia  in the anaesthesia record includes (Michelle & Mary, 2011) the following records:

  1. anaesthetic agents administered, including amount, technique(s) used, effect on patient, and duration
  2. patient’s vital signs (e.g., temperature, pulse, blood pressure) enhanced by the use of a monitoring equipment such as the anaesthesia workstation
  3. other activities related to the surgical episode like any blood loss, transfusions administered, including dosage and duration, IV fluids administered, including dosage and duration
  4. the patient’s physiological status immediately after recovery from anaesthesia

If your hospital shows the (a) existence of a policy and procedures that address the standards required for the (i) minimum frequency of monitoring, (ii) type of monitoring,  (iii) process of monitoring of the physiological status during the administration of anaesthesia and immediately after recovery from anaesthesia is uniform for similar patients receiving similar anesthesia wherever anesthesia is provided, and when (b) all the results of monitoring during anaesthesia are written into the patient’s anaesthesia record, I think it is safe to conclude that your hospital fully meets the JCI Standard ASC.5.3 and its three (3) Measurable Elements requirements for documentation of monitoring of the patient during administration of anaesthesia.

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

Documentation by the surgeon prior to surgery

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Surgery also often called an “operation”, is an invasive process because an incision is made into the body to repair or remove or replace a part of body tissues or organs as the best treatment for his or her disorder.

As surgery always carries a high level of risk, the surgeon will assess each patient and weigh the surgical risk against the need for surgery.

In some cases, surgery must be done despite the high level of risk due to the presence of risk factors, for example the common instance of  patients presenting for surgery with a pre-existing physical disorder risk factor from diabetes mellitus, with slowed healing, increased incidence of infections, insulin imbalances, inability to regulate blood sugar levels.

When a person is brought in by ambulance and must receive immediate surgery, this emergency patient needs emergency surgery. The assessment process for an emergency patient is carried out in a shortened time frame and the surgery performed immediately to save the patient’s life. Examples are ectopic pregnancy with threat of rupture, severe internal hemorrhage, ruptured appendix, and angioplasty after a heart attack.

So in most normal circumstances, patients for which surgery is planned have a medical assessment and all required tests performed before the surgery. Assessment(s) provide information necessary to :

  1. select the appropriate procedure and the optimal time identified from sequencing the assessments in the clinical care path on a timeline for the patient
  2. perform procedures safely
  3. interpret findings of patient monitoring

The selection of an appropriate invasive procedure considers information from the following sources used to develop and to support the planned invasive procedure by the responsible surgeon before the procedure is performed :

  1. the initial medical and nursing assessment(s) on the patient’s history and physical status
  2. available results that have been reported within a time frame to meet the patient needs (in this case the impending surgery) for all required tests, such as electrocardiogram (ECG), ordered laboratory tests, radiology and diagnostic imaging study

The surgical care planned for the patient is documented in the patient’s medical record, more so if the hospital is seeking or plans to continue maintaining accreditation status  dictated by standards from a hospital quality assurance agency like that of the Joint Commission International (JCI). The JCI standard on documentation by the surgeon prior to surgery is the  Standard ASC.7, which states that “Each patient’s surgical care is planned and documented based on the results of the assessment”, requires the surgeon to document the following prior to performing surgery :

  1. procedure selected
  2. a preoperative diagnosis in the Preoperative Note which is a progress note documented by the surgeon prior to surgery, which summarizes the patient’s condition – the name of the surgical procedure alone does not constitute a diagnosis (JCI 2011)

However I think documentation on the surgical care plan should also incorporate the following although they are not mentioned to meet JCI Standard ASC.7 :

  1. emotional support provided to the patient and the family, especially to the patient who faces surgery as the patient may compare the previous experience with this one and can be particularly frightened if the patient has had any previous experience with surgery which was difficult or the patient facing surgery for the first time may be apprehensive about pain, about losing consciousness, fearful of cancer or of being disabled or worse still some others maybe afraid they will die
  2. preparation of the patient physically for surgery for example a surgical preparation or “prep” is done by cleaning the skin with an anti-infective agent and may be shaved when an incision is to be made in the skin
  3. that all legal matters, such as signing the surgical consent (informed consent), are carried out
  4. routine preoperative care provided

JCI does not say where in the medical record the surgical care plan should be documented. From my experiences, these are often documented in the progress notes and are authenticated by the responsible surgeon.

In summary, If documentation is completed as above in the medical record of a patient prior to surgery, then the hospital seeking or planning to continue maintaining accrediation status from JCI,   will fully meet  JCI’s Standard ASC.7 and it’s four (4) measurable elements.

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