Category Archives: JCI

Standards with requirements that require documentation in a medical record

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The rush for Joint Commission International (JCI) accreditation and certification has spread across Asia – from Turkey and Jordan to China and Singapore, and of course to Malaysia too.

In the wake of this rush by many hospitals which are on their way to acquire what is known as a “Gold seal of Quality”, an international accreditation award given to healthcare establishments internationally if they meet or exceed JCI standards by JCI based in the United States, I think it is imperative that Health Information Management (HIM) / Medical Records (MR) practitioners working in such hospitals must examine how JCI accreditation and certification affects them and what they must do to thrive under it.

In this post and in subsequent posts, read about the aspects of JCI accreditation and certification that directly affect medical information and surgical information that require documentation in medical records, and to learn about the role of care providers play for what portions of both medical and surgical information that must be recorded in the medical record (what they say) from what they do to improve quality of patient care and reduce costs in this quality system of accreditation and certification.

Allow me to lead you along the path of another new post after this one, to aspects of  this quality system of accreditation and certification from JCI that directly affect medical information that require documentation in medical records.

But before that, some rules to identify the standards and the requirements found in the Joint Commission International Accreditation Standards For Hospitals 4th Edition relevant to medical information and surgical information, that require documentation in a medical record which form the greater part of what is called “the contents of a medical record”.

Familiarity with the Joint Commission International Accreditation Standards For Hospitals 4th Edition indicates that JCI has standards which explicitly state what is to be documented in a medical record and also has standards which implicitly hints what is to be documented in a medical record.

Standards which explicitly state in the standard statement and / or  in a corresponding Measurable Elements (ME) of each standard what is to be documented in a medical record contain statement(s) and /or phrases like :

  • Standard AOP.1.3 statement which states “The patient’s medical and nursing needs are identified from the initial assessments and recorded in the clinical record.”
  • Standard ASC.5.2 statement which states “The anesthesia used and anesthetic technique are written in the patient record.”
  • “documented in the patient’s clinical record”
  • “entered into the patient’s clinical record”
  • “recorded in the patient’s record”
  • “written in the patient’s record”

For example, Standard AOP.1.3 states “The patient’s medical and nursing needs are identified from the initial assessments and recorded in the clinical record.”, and has two MEs that explicitly state what is to be documented in a medical record, namely ME3 and ME 4 which state “The identified medical needs of the patient are documented in the patient’s clinical record.” and “The identified nursing needs of the patient are documented in the patient’s clinical record.”, respectively.

Standards which implicitly hint to what is to be documented in a medical record have words or phrases or complete statements which hint of documentation of what is to be included in a medical record like :

  • “The clinical records of inpatients contain a copy of the discharge summary.”, which is the Standard ACC.3.2 statement
  • “The initial assessment(s) results in an initial diagnosis” which is the ME 4 for the Standard AOP.1; an initial diagnosis is obviously a medical information by a doctor
  • “Patient records contain a list of current medications taken prior to admission, and this information is made available to the pharmacy and the patient’s health care practitioners.” which is the ME 5 for the Standard MMU.4

For example, the Standard ACC.3.2 states “The clinical records of inpatients contain a copy of the discharge summary.” and its corresponding ME 3 states “A copy of the discharge summary is placed in the patient record.”

Standards which explicitly state what is to be documented in a medical record and standards which implicitly hint what is to be documented in a medical record, make up the “requirements”  to form the greater part of the contents of a medical record. To make it clearer, I mean to say “requirements” refers to what goes into a medical record.

Image credit : http://www.ppt-learning.com/

I guess I have made the rules clear for an understanding of my next post on medical information that warrants documentation in a medical record.

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

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