Category Archives: JCI

Assessments before Anesthesia or Surgery

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Preoperative assessment is the assessment done before surgery, i.e the phase when a patient is prepared for surgery in the time span that includes preparation for, the process of, and recovery from surgery.

Gathering of prompt and accurate initial medical assessment information about the patient before surgery helps to ensure a successful outcome for the patient.

This information gathering is largely a nursing function, with assessments also done by the surgeon, the anesthesiologist or a registered nurse anesthetist (RNA).

What you need to know as a Health Information Management / Medical Records practitioner is that patients for whom surgery is planned have a medical assessment performed before the anesthesia or surgery as required by the JCI Standard AOP.1.5.1, ME 1, and this medical assessment of surgical patients is documented in the medical record before surgery as required by the JCI Standard AOP.1.5.1, ME 2.

Maybe it is good to know what kind of data is gathered in an initial medical assessment before anesthesia or surgical treatment.as required by the the JCI Standard AOP.1.5.1 and what goes into the medical record you keep.

Assessment before aneasthesia or surgery includes :

  • observations by the nurse – any unusual reactions or observations recorded in the patient’s medical record and reported to the charge nurse or surgeon at once
  • vital signs the morning of surgery and any significant deviation from normal recorded and reported
  • a general systems review, noting in particular any new cardiopulmonary developments that place the patient at highrisk during surgery
  • a complete physical examination, including laboratory tests and their results recorded in the patient’s record and, if abnormal, reported to the surgeon or their representative – for nonemergency surgery, laboratory tests done about a week before the procedure.

Routine, preoperative laboratory tests often include :

  • a chest x-ray
  • complete blood count (CBC)
  • urinalysis (UA)

Other laboratory tests and examinations will include:

  • a metabolic panel
  • a toxicology screen, if there is a possibility of alcohol or drug abuse.
  • a pregnancy test may be done, to determine what, if any, medication can be used. are performed as needed
  • an electrocardiogram is usually obtained for all patients older than 40 years
  • blood is drawn for a type and cross match if any possibility exists that a blood transfusion will be needed during surgery
  • patient’s weight is documented in kilograms, because dosages of medications, including anesthetics, are usually calculated on the basis of the patient’s kilogram weight
  • a visit from the anesthesiologist or nurse anesthetist (RNA) before surgery enables a patient to ask questions that may be troubling him or her and allows the anesthesiologist or RNA to assess the patient based on the assessment findings listed above – “patient management by anesthesiologists is generally highly standardized and includes some of the most robust safety engineering found in health care”, (ACMQ 2010).

As I end this post, I wish to record that this posting brings back memories of my multifaceted experiences, skills acquired and the joy when I worked as a medical assistant (an equivalent to a male nurse) in my start-off, one singular career phase of my life.

References:
American College of Medical Quality, 2010, Medical quality management : theory and practice, 2nd edn, Jones and Bartlett Publishers, Sudbury, MA, USA

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

JCI Standard MCI.2 – Communication with Patients and Families, about care and services and how to access those services

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JCI Standard MCI.2 states clearly that “The organization informs patients and families about its care and services and how to access those services.”, thereby a hospital must meet 3 of its requirements to match this standard.

Let us now see what a hospital must do to live up to the expectations and hopes of sick patients and their families when they get to a hospital.

Organisation ethics requires that a hospital offer to inform patients and their families complete information they wish to know on the care and services at the hospital. Patient and families have a right to reasonable access to care as well as how to access those services. Information provided also includes information on the proposed care for a patient.

This openness and trustworthiness shown by a hospital when it works to build and establish trust and open communication with patients and their families, and when it also trys to understand and protect each patient’s cultural, psychosocial and spiritual values, helps create a bond between patients and their families.

Let’s now see how the Joint Commission International quality standards fits into this picture of openness by a hospital.

By providing all the needed information with the openness of the hospital, awareness and knowledge gained and learnt of the care and services through this openness, trust bonded between patients and their families and the hospital, the hospital easily complies with two of the JCI Standard MCI.2 requirements  namely ME 1 and ME 2.

If the hospital includes information on the proposed care for a patient.in its initial plan to inform patients and their families, then the hospital meets the requirement by the JCI Standard ACC.1.2, ME 2

At the hospital, it is only normal when patients and their families learn of the hospital’s capability to match their expectations of care and services.

When patients and their families learn that their needs fall beyond the scope of  the hospital’s competence, mission and capabilities, then the hospital is obligated to provide information to the patient and their families on alternative sources of care and services. Such alternative sources of care and services may be available at another hospital in the district, and the hospital then co-ordinates with the other hospital with the needed services, and ensures that such patients are appropriately referred to the other facility with services that meets their ongoing care needs.

The hospital will thus comply with the JCI Standard MCI.2 requirement ME3 if the hospital is able to provide information to the patients and their families on alternative sources of care and services when their needs fall beyond the scope of  the hospital’s competence, mission and capabilities.

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

Documentation of medication administration in medical records

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Joint Commission International defines medication (JCI 2010) as ‘any prescription medications; sample medications; herbal remedies; vitamins; nutriceuticals; over-the-counter drugs; vaccines; or diagnostic and contrast agents used on or administered to persons to diagnose, to treat, or to prevent disease or other abnormal conditions; radioactive medications; respiratory therapy treatments; parenteral nutrition; blood derivatives; and intravenous solutions (plain, with electrolytes and/or drugs.’

Preparation for medication administration in a hospital begins with the order for medication, in most circumstances written by a doctor. A record of orders for medication (medications prescribed or ordered), the dosage and times the medication and other treatments was administered is kept in the medical chart of each patient.

Frequency of administration is most often ordered on a repeating schedule (ie, every 8 hours). At times the order may be written as a STAT (give right away) order, a one-time order (give just once) or a prn (medications administered “as needed”) order. Standing orders (also referred to as scheduled orders) are administered routinely as specified until the order is canceled by another order.

Before administration and to ensure safe administration, medication records are strictly on hand at time of administration and medication given according  the “five rights” namely:

  1. Right patient
  2. Right drug
  3. Right route
  4. Right dose
  5. Right time

Documentation of medication administration is an important responsibility. The medication record tells the story of what substances the patient has received and when. Like other health care records, it is also a legal document.

Hospitals usually have policies and procedures regarding documentation of medication administration. Such policies and proceudres would entail that a listing of all current medications taken prior to admission must be recorded in the patient’s medical record and is available to the pharmacy, nurses, and doctors. An established process contained in such medication related procedures may include that this listing of ‘all current medications taken prior to admission’ is readily available so that it can be used to compare with ‘initial medication orders’.

Now, just in case your hospital is been prepared for JCI accreditation, the medical records you keep must comply with two JCI standards to meet its requirements for proper documentation of medication administration.

The first of the two standards mentioned above which your hospital needs to comply with is JCI Standard MMU.4, which states that ‘Prescribing, ordering, and transcribing are guided by policies and procedures.’

Medical, nursing, pharmacy, and administrative staff in your hospital actively collaborate to develop and monitor such policies and procedures.This standard guides the safe prescribing, ordering, and transcribing of medications.

What concerns you as the Health Information Management/Medical Records practitioner directly is the process of transcribing of medications (by doctors, usually the clerking doctor at admission), which includes ‘a listing of all current medications taken prior to admission’ that must be duly recorded in a patient’s medical record, which will then be measurable for complaince by JCI Standard MMU.4, ME 5.

However, do take note your hospital must comply with JCI Standard MMU.4, ME 6 which requires that this listing is important to be maintained in a medical record since it is used to make a comparison between ‘all current medications taken prior to admission’ against ‘initial medication orders’.

The other direct concerns to you when your hospital is been prepared for JCI accreditation is to be beware that your medical records must contain medication documentation as required by JCI Standard MMU.4.3 which states ‘Medications prescribed and administered are written in the patient’s record’ and that this documentation in your medical records have evidence that can show:

  • medications prescribed or ordered are recorded for each patient that is measurable by JCI Standard MMU.4.3, ME 1
  • medication administration is recorded for each dose, measurable by JCI Standard MMU.4.3, ME 2
  • medication information is kept in the patient’s record or inserted into his or her record at discharge or transfer, measurable by JCI Standard MMU.4.3, ME 3

In summary, in case your hospital is been prepared for JCI accreditation, then look out for JCI Standard MMU.4 and its two requirements ME 5 and ME 6, and also JCI Standard MMU.4.3 and its three requirements namely ME 1, ME 2 and ME 3, so that the medical records you keep complys with these two JCI standards and so to meet its five respective requirements for proper documentation of medication administration.

References:
Carol, T, Carol, L & Priscilla, L 1997, Fundamentals of Nursing: The Art of Science of Nursing, 3rd edn, Philadelphia: Lippincott-Raven Publishers

Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

Janet, W & Jane, HK 2010, Health assessment in nursing, 4th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

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

Patricia, AP & Anne, GP 1997, Fundamentals of Nursing: Concepts, Process, and Practice, 4th edn, St Louis, USA, Mosby-Year Book, Inc.

Work Not Documented Is Work Not Done

Pain assessment findings documentation in medical records

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I think as Health Information Management(HIM)/Medical Records(MR) practioners, it is never objectionable to know the background on pain assessment documentation found among the contents of a medical record.

A background I would consider knowing about is what is pain all about, how pain is managed including the assessment process, the tools used to measure pain, and pain assessment documentation.

Pain which is now considered to be the fifth vital sign, is also assessed whenever the other four vital signs namely temperature, pulse, respiration, and blood pressure are measured.  Patients are asked on a regular basis if they are experiencing pain. The evaluation of pain, along with other vital signs, alerts the nurse and other healthcare providers to the necessity of addressing the patient’s pain. Relief of pain helps the patient to be more comfortable and to recover more quickly.

What is pain then?

Because pain is a subjective symptom which only a patient can describe it, pain is difficult to define. However we know as humans that pain is the body’s signal of distress, and is very difficult to ignore. Most of us try many remedies to relieve pain, often without success. Ultimately, it is one of the most common reasons that most of us seek healthcare.

Here I list some notable definitions of pain, a universal human experience:

  • ‘Pain is whatever the experiencing person says it is, existing whenever he says it does’, stated by pain theorist, Margo McCaffery
  • The Agency for Healthcare Research and Quality (AHRQ) in its clinical practice guidelines for acute pain management states that the ‘client’s self-report is the single best indicator of pain’
  • One definition of pain in a medical dictionary includes ‘a feeling of distress, suffering, or agony, caused by stimulation of specialized nerve endings’
  • The International Association for the Study of Pain defines pain as ‘An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage’

Pain is classified in several ways. Duration and etiology are often classified together to differentiate acute pain, chronic nonmalignant pain, and cancer pain. Pain location classifications include cutaneous pain, visceral pain, and deep somatic pain, radiating, and referred. Phantom pain can be perceived in nerves left by a missing, amputated, or paralyzed body part. Other types of pain are neuropathic pain and intractable pain.

I am sure you would have noticed these terms used in the medical record in the course of reading the medical record, example for ICD-10 coding purposes.

The experience of pain is quite complex and the multidimensional complexity of pain can be described in seven dimensions: physical, sensory, behavioural, sociocultural, cognitive, affective, and spiritual.

Pain is managed with the use of pharmacological (oral medication, Intravenous Medication (IM), Intravenous Venous (IV) medication, IV continuous medication) and non- pharmacological interventions (which may include warm and cold compresses, heat and cold applications at a Rehabilitation Department, position change and relaxation exercises to control the patient identified pain). Pharmacological and non-pharmacological interventions extend beyond pain relief, encompassing the patient’s quality of life, and ability to function or work productively. Pain relief after surgery is improved with the combined use of different classes of analgesic. There may also be an associated reduction of the dose of each analgesic drug and the intensity of any side effects.

Patients are assessed appropriate to patient’s age:

  • within one hour on admission to the ward, including Day Surgery and Endoscopy
  • upon inter-ward transfer
  • at the beginning of each outpatient visit to the departments such as the AE, Rehabilitation Department, Oncology Centre
  • following a surgical procedure or treatment
  • when the patient complains of pain
  • before and after administration of medication and / or treatment.
  • at time of discharge

Allow me now to go on and discuss the pain assessment tools and findings documentation found in medical records.

Pain screening is very important in developing a comprehensive plan of care for the client. Therefore, it is essential to assess for pain at the initial assessment. Pain intensity measurement tools such as a 1 to 10 Likert scale may be used.

There are many pain assessment scales; for example, Visual Analog Scale (VAS), Numeric Pain Intensity Scale (NPI), Simple Descriptive Pain Intensity Scale, Graphic Rating Scale, Verbal Rating Scale, and Faces Pain Scales (FPS, FPS-R), and the more common Wong-Baker Faces Pain Scale (a picture scale).  You can find out more on some of these scales from http://www.partnersagainstpain.com/measuring-pain/assessment-tool.aspx (this link will open in a new tab of your current window).

While there are no laws in Malaysia that  necessitates pain assessment and documentation, some states in the United States have passed laws necessitating the adoption of an assessment tool and documenting pain assessment in patient charts along with temperature, pulse, heart rate, and blood pressure.

So what is important for you as a HIM/MR practitioner is that pain assessment findings and treatment are documented in the patient’s record and readily available to those responsible for the patient’s care.

However if you working in a hospital in the process of accreditation,  for example using the Joint Commission International(JCI) quality standards , then it is important to know the JCI requirements to improve the management of pain which are as follows:

  • patients have the right to appropriate assessment and management of pain
  • on-going pain assessment should include the nature and intensity of pain, thus the use of pain scales to help clients determine their level of pain
  • responses to evaluation of pain should be recorded in a manner that promotes regular reassessment and follow-up
  • staff must be oriented and competent in assessment and management of pain
  • policies and procedures supporting ordering of pain medications must be in place
  • patients and families require education about effective pain management.
  • discharge planning should address the patient’s needs for management of pain

The JCI requirement that specifically requires that the medical record contain documentation on pain assessment is non-other than the JCI Standard AOP.1.7 which states that ‘All inpatients and outpatients are screened for pain and assessed when pain is present.’

The intent of JCI Standard AOP.1.7 is to ensure that a screening procedure is used to identify patients with pain during the initial assessment and during any reassessments. When pain is identified and when the patient is treated in the hospital, then this assessment is recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the hospital and the patient’s needs. JCI Standard AOP.1.7 Measurable Element (ME) 3 then measures if the medical records have evidence that ‘the assessment is recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the hospital and the patient’s needs.’

References:
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

Janet, W &Jane, HK 2010, Health assessment in nursing, 4th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

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

PartnersAgainstPain.com website

Informed Consents – 5 required documentation in the medical record providing information to patient and family

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“Every human being of adult years and sound mind has a right to determine what shall be done with his own body….”, is an often quoted (in bioethics and legal literature) statement by Justice Cardozo from the well-known case Schloendorff v. Society of New York Hospital, 105 N.E. 92, 1914.

Informed consent as Wikipedia informs us “is a phrase often used in law to indicate that the consent a person gives meets certain minimum standards”. It is interesting to note that this term was first used by Paul G. Gebhard, an attorney well educated from Yale and Harvard Law School and the senior partner in the government, health care and association group of the Chicago law firm of Jenner & Block, in a 1957 medical malpractice case in which a patient contended that a physician at a Stanford University hospital had not fully disclosed the risk in a recommended treatment.

As an informed consent grants the right to a patient to be involved in their care decision, the inform consent informs a patient of those factors related to the planned care required for an informed decision.

Informed consent can be obtained when at several points in the care process. Informed consent can thus be obtained when a patient is admitted for inpatient care before certain procedures or treatments for which the risk is high.

It is important to know the following:

  • the consent process is clearly defined in the hospital’s policies and procedures incorporating relevant laws and regulations
  • the role patients and families in the informed consent process – (i) they are informed as to what tests, procedures, and treatments require consent and how they can give consent (for example, given verbally, by signing a consent form, or through some other means), (ii) they understand who may, in addition to the patient, give consent
  • trained designated staff members inform patients, obtain and document patient consent. Here I like to quote the Malaysian Medical Council  (MMC) which “upholds that the responsibility for obtaining consent lies with the  practitioner performing the procedure. He is the best person who can ensure that the necessary information is communicated and discussed”,  as stated in its “A Guidebook for House Officers”, paragraph 4.12, pages 37-38, dated 23 April 2008. A statement from a booklet by the MMC,  “Good Medical Practice”,  paragraph 3.7, page 13 also defines and states the role of doctors in providing an informed consent.

Now that you as a HIM/MR practitioner finished reading from the above a brief overview of the basic human right of a patient to informed consent, you need to know the kind of documentation that goes into a medical record.related to informed consent which is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures.

A medical record will contain an informed consent for :

  1. surgical or invasive procedures
  2. anesthesia other than local including moderate (“conscious”) and deep sedation
  3. blood and blood products used
  4. high-risk procedures and treatments

When informed consent is taken, the following will also be recorded in a medical record:

  1. identity of the individual providing information to patient and family
  2. patient’s signature or a record of verbal consent

Thus,  the 5 required documentation in the medical record providing information to patient and family includes numbers 1 to 4 as given above and number 5, ” identity of the individual providing information to patient and family and the patient’s signature or a record of verbal consent”

Whether or not your hospital is been accredited by the Joint Commission International(JCI), you need to play your role to ensure that an informed consent is documented in the medical record when a patient had surgery, anesthesia, used of blood and blood products, and undergone other high-risk treatments and procedures.

If you hospital is been accredited by JCI, then you must be informed that JCI Standard *PFR.6.4 applies to an informed consent documentation in a medical record. JCI Standard PFR.6.4 states that “Informed consent is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures”.

Still on the subject of JCI accreditation, it’s good to be aware not only of JCI Standard PFR.6.4, but also I think as an informed HIM/MR pratitioner to also know the following too:

  1. that a hospital has a clearly defined informed consent process described in policies and procedures
  2. who are trained to implement these policies and procedures
  3. what is clearly explained regarding any proposed treatment(s) or procedures to the patient and, when appropriate, the family

In addition, be informed that:

  1. designated staff members who are trained, not only to carry out the process of giving out the informed consent but also obtain and document patient consent in accordance to the  JCI Standard PFR.6 which states that “Patient informed consent is obtained through a process defined by the organization and carried out by trained staff in a language the patient can understand”.
  2. these trained designated staff members provide information as stated the elements (a) to (h) as in the JCI Standard PFR.6.1 which states that “Patients and families receive adequate information about the illness, proposed treatment(s), and health care practitioners so that they can make care decisions”

So much more to be informed on informed consent, and I think I covered pretty much already on JCI Standards PFR.6, PFR.6.1 and PFR.6.4

*PFR stands for Patient Family Rights