Category Archives: Hospital Accreditation

Medical records should contain the patient’s educational needs assessment documentation

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The Seven Dimensions of Patient-Centered Care described by the Picker Institute Inc., an international non-profit organisation dedicated to advancing the principles of patient-centered care through education, research and the public recognition of best practices,  provide an excellent starting point for any hospital to begin a customer focused improvement effort. These dimensions of care can be viewed from the image below.

Image credit : http://pickerinstitute.org/about/picker-principles/

I shall focus my discussion of this post with reference to two (2) out of these 7 dimensions, namely (i) involving information, communication and education and (ii) the involvement of family and friends.

As consumers (patients) or as member(s) of the patient’s family, many readers are already acquainted with the situation when you as the patient or as member(s) of the patient’s family believe that information is often being withheld from you or your family and that they are not being completely informed about their condition or prognosis. The patient or  as member(s) of the patient’s family often experience anxiety over clinical status, treatment and prognosis, the impact of the illness on themselves and family, and the financial impact of illness.

Many readers will also be already acquainted with the situation when you as the patient will address the role of your family and friends with your hospital experience, often expressing concern about the impact your illness has on your family and friends.

In recognition of the needs of family and friends and the involvement of family and friends, a hospital and its doctors, nurses and other caregivers must accommodate family and friends on whom the patient relies for social and emotional support, and also give support for family members as caregivers as well as to support the patient “advocate’s” role in decision-making of the care process.

Image credit : http://fibrocarecenter.com/

It is only appropriate that  any hospital dedicated to advancing the principles of patient-centered care through education provides patient/family education to enhance the patient/family knowledge, skills, and behaviours s/he needs to restore quality of life and make informed health care decisions.

Patient/family education is initiated at the time of admission and, as needed, throughout the patient’s stay at the hospital.

Education by the hospital staff is provided to patients and families when a patient or family directly participates in providing care (for example, changing dressings, feeding the patient, administering medications and treatments), they need to be educated.

Education focuses on the specific knowledge and skills the patient and family will need to make care decisions, participate in their care, and continue care at home. This is in contrast to the general flow of information between staff and the patient that is informative but not of an educational nature.

But in order to understand the educational needs of each patient and his or her family, assessments are done to evaluate if:

  1. the patient mutually meets established goals and objective
  2. ihe patient’s attitudes has changed
  3. the patient can cope better with illness imposed limitations
  4. identify the types of surgeries, other invasive procedures and treatments planned and if the patient understands the accompanying nursing needs
  5. the family understand health problems and know how to help
  6. the patient and family understand and can demonstrate skills the continuing care needs following discharge

This assessment permits the patient’s care givers to plan and to deliver the needed education. Once the educational needs are identified, they are recorded uniformly by all staff in the patient’s medical record. This helps all the patient’s caregivers participate in the education process.

Education is also provided as part of the process of obtaining informed consent for treatment (for example, for surgery and anaesthesia) when patients and families learn about the process for granting informed consent.

Overall, education by the hospital staff makes patients and families learn:

  1. about how to participate in care decisions
  2. about their conditions and any confirmed diagnoses
  3. their rights to participate in the care process

At hospitals that are Joint Commission International (JCI) accredited or seeking JCI accreditation status or re-applying for JCI accreditation status, they are required to comply with the JCI Standard PFE.2 which requires that each patient’s educational needs are assessed prior to providing the appropriate levels of education.

The JCI Standard PFE.2 also requires that a patient’s medical records should contain the patient’s educational needs assessment documentation. Such documentation includes the following:

  1. assessment and identification of educational needs
  2. the patient’s ability to learn/understand the information
  3. teaching interventions to meet identified needs
  4. the patient/family understanding of the instruction or education provided

Documentation of patient/family education could be located on a special form, for example a Multidisciplinary Education Form/ Patient Education Sheet or in progress notes.

I think it is appropriate that Health Information Management (HIM) / Medical Records (MR) practitioners should give comments when a hospital reviews, plans and decides the location and format for educational assessment, planning, and delivery of information in the patient’s medical record.

The JCI Standard PFE.2 is listed in the Medical Records Review Tool form to check for compliance against this standard during a Medical Records Review process.

References :
Diane, LK 2007, Applying quality management in healthcare : a systems approach, 2nd edn, Health Administration Press, Chicago, Illinois, USA

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

Picker Institute, Principles Of Patient-Centered Care, viewed 9 September 2012, <http://pickerinstitute.org/about/picker-principles/>

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

JCI Standard MCI.20 – Aggregate data and information must support the quality management program of a hospital

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The post JCI Standard MCI.20 – Aggregate data and information support patient care, organisation management, and the quality management program (this link will open in a new tab of your current browser window) supported how aggregate data and information support patient care and organisation management. This post will continue where I left off from there, and now discuss further on the Joint Commission International (JCI) Standard MCI.20 which requires that aggregate data (based on performance, utilisation, and resource management) and information also support the quality management program of a hospital.

But before I change to higher gears and bring you coverage of activities on the quality management program of a hospital, I am sure Health Information Management (HIM) / Medical Records (MR) practitioners following this blog will be wondering if they can skip this post as they might postulate that quality management programs have nothing to do with HIM/MR management. I think HIM/MR practitioner readers need to hold on and read on as they have a role to play in the quality management program of a hospital.

To be honest there is so much to write about this area of concern but I think I shall restrain myself to be brief but as complete as possible. I shall relate the role of HIM/MR practitioners play where I think they need to.

During their formative training, HIM/MR practitioners may become aware that some licensed professionals or hospital staff are involved in utilisation review, quality improvement, utility system management, infection prevention and control, and risk management activities; but I am think only few are aware of the rich scientific base and health tradition that frames these fields. Let’s understand these activities first.

Utilisation management (UM) or Utility System Management (USM) activities directly impact the quality of outcomes through the most efficient and effective manner of delivering health care for the patient and the population. A mix of clinical, administrative, and financial methods are used to evaluate the appropriateness, the processes, the facilities, and the providers of care.

The UM process includes interventions that take place before, during, and after a clinical event occurs. Data for this process must be accurate, timely, relevant, and easily collectible at a reasonable cost. Defensible administrative or clinical types of data that have been validated are used when evaluating performance for UM. HIM/MR practitioners can anticipate that clinical data in medical records will be used in the design and data collection for UM studies.

My experiences in measuring and improving hospital quality provides insights that quality improvement is an important challenge in any attempt to improve the health care system. The Agency for Healthcare Research and Quality (AHRQ) describes quality improvement (QI) as “doing the right thing at the right time for the right individual to get the best possible results.” Continuous Quality Improvement (CQI) is a tool that can be used to respond to identified problems, prevent problems, and improve upon the status quo. Total Quality Management (TQM) on the other hand is a management philosophy that emphasises a commitment to excellence throughout the organisation; implemented in combination with CQI.

Information management involving HIM/MR practitioners enables hospitals to support patient safety improvement efforts by providing accurate and complete data. HIM/MR practitioners must be able to identify data elements for use in quality and patient safety measures and ensure these measures are being reported correctly and resolve any issues that may exist with data consistency and completeness. HIM/MR  practitioners should also identify opportunities to participate in standards development or reviews at the hospital and provide reviews and comments on new and revised standards and quality and patient safety measures.

A nurse administered the wrong medication to a patient. A visitor slips and falls on a wet floor, even though the wet floor was well-marked. The wrong medication to a patient is a medical error, while when the visitor slipped and fell on a wet floor, is an accident that results in personal injury. Medical error or an accident that results in personal injury or loss of property are all circumstances that put patients, visitors or a hospital at risk for adverse outcomes. Incident reports are generated on patients and visitors about a potentially compensable event (PCE).

Risk management is about identifying circumstances that put patients, visitors or a hospital at risk, been responsible for coordinating and monitoring risk management activities, analysing trends of incidents, and establishing priorities for dealing with high-risk areas, and putting into operation methods that avoid, prevent, and control such risks. The goal is to ensure patient safety.

HIM/MR practitioners need to know that incident reports are considered a secondary source of patient information. They must ensure that incident reports are never filed in the patient’s medical record, so that incident reports are not subject to disclosure (release) when patient records are subpoenaed or requested (e.g., by an attorney) upon patient authorisation. Incident reports are filed with the hospital’s risk management office or the quality assurance department.

The infection prevention and control process is designed to lower the risk of infection for patients not present on admission, staff, and others. To reach this goal and minimise their overwhelming consequences in terms of cost, morbidity, and mortality, a hospital proactively identifies and track risks, rates, and trends in health care–associated infections (HAI).

A hospital uses measurement information to improve infection prevention and control activities and to reduce HAI rates to the lowest possible levels through consistent, mindful adherence to basic infection control principles and measures which include for example, hand decontamination upon entering and leaving every patient encounter – usually referred to as universal precautions, a critical protective strategy.

A review of 20 medical records for patients who received a overmedication for a particular drug is likely to yield a much higher incidence of overmedication for the particular drug than a random sample of 20 medical records. A more thorough review of the medical records gathers information to help develop a collective picture of a practice that can identify the outlier or unusual event (in this case overmedication for a particular drug) during a particular procedure/process (in this case medication for a particular drug). Screening medical records in this way for the presence of adverse events is a tool for data acquisition for a morbidity and mortality committee to identify contributory factors, which indicate areas for improvement and prevention.

Much of the discussion above is an important part of the hospital’s performance improvement activities with the intent to gather and aggregate data that can be used to create safety alerts and tips, to identify and showcase best practices, and to highlight trends. Aggregate data and information must be seen to support the quality management program of a hospital in order to comply with JCI Standard MCI.20, ME 3, and if in any case help the hospital understand its current performance and identify opportunities for improvement.

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

Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn,  Jones and Bartlett Publishers, Sudbury, MA, USA

General consent is not informed consent

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If you are a patient presenting for a routine health care service, for example  general medical, paediatric, family planning, obstetric, Immunization, STD, TB, and/or HIV clinic services, then you will asked to fill up a  general consent  form to be completed prior to any of these services being rendered.  This is not informed surgical or invasive procedure consent form.

Image credit : Tung Shin Hospital, Kuala Lumpur, Malaysia <http://www.tungshin.com.my/useful-info/admission-discharge/>

The general consent is usually obtained when the patient is admitted as an inpatient to the hospital or when the patient is registered for the first time as an outpatient.  However in the U.S., the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule “permits, but does not require, a covered entity voluntarily to obtain patient consent for uses and disclosures of protected health information for treatment, payment, and health care operations. Covered entities that do so have complete discretion to design a process that best suits their needs.”

Patients are given information on the scope and limits of the general consent, such as which tests and treatments are included under the general consent. Patients are also given information about those tests and treatments for which a separate informed consent will be obtained.

The hospital defines how a general consent is documented in the patient’s medical record, for example the general consent to treatment may be located by a Health Information Management (HIM) / Medical Records (MR) practitioner.to be found on the reverse of the face sheet (or admission/discharge record).

General consent forms are also used at teaching hospitals and patients are advised that doctors, nurses and other healthcare professionals in training will be involved in the patient’s care and treatment.

A general consent usually contains information as follows:

  1. a general consent form authorises the attending doctor, other doctors and healthcare professionals who may be involved in a patient’s care, to provide a diagnosis, care and treatment considered necessary or advisable by the doctor(s)
  2. the general consent form does not guarantee the patient about the result of his or her examination or treatment at the hospital
  3. the general consent notes if it is likely that students and other trainees will participate in care processes
  4. provisions in the general consent form inform patients that their decision to seek care from a hospital is not based upon any understanding, representation or advertisement that the doctors treating them are employees, agents or apparent  agents of the hospital, and that they also understand that they have the opportunity to request that their own doctor participate during in their care at the hospital
  5. the general consent form may also authorise a hospital to examine, use, store and dispose of any tissue, fluids or specimens removed from a patient’s body during his or her outpatient visit or hospital stay

Agreeing to a general consent for treatment by a patient before admission as an inpatient or been registered for the first time as an outpatient, may apply at any (Malaysian) hospital setting. However, hospitals that are Joint Commission International (JCI) accredited or seeking JCI accreditation status or re-applying for JCI accreditation status  need to comply with the JCI Standard PFR6.3 which implies that “General consent , is clear in its scope and limits.” The medical record must contain a copy of the general consent in any hospital setting.

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

U.S. Department of Health & Human Services, What is the difference between “consent” and “authorization” under the HIPAA Privacy Rule?, viewed 4 September 2012 < http://www.hhs.gov/hipaafaq/use/264.html>

Surgical information that require documentation in medical records

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Now I have completed relevant posts on surgical information that belong to the contents of a typical medical record for a patient who had undergone surgery, I like to summarise the Joint Commission International (JCI) standards and requirements that directly affect surgical information which requires documentation in medical records.

At this juncture, I like to reiterate that I am not advocating JCI’s program for hospital accreditation. I have used their standards as a benchmark to make medical records documentation to a better quality and as evidence of proper care.

I have also run up each post with a background to a specific surgical information in the medical record, so that Health Information Management (HIM) / Medical Records (MR) practitioners are not just managing medical records literally and not understanding and knowing the background of pieces of scientific information which accumulates inside the medical records.

In my opinion, knowing the nature and structure of surgical information in a medical record make a better HIM/MR practitioner, who is able to stand up for and argue for the quality of medical and surgical information in medical records.

Someone has to fight for the quality of medical records, and who is less important and relevant than HIM/MR practitioners who are the rightful custodians of medical records. I think it is not HIM/MR management practice is not only about medical records assembly, filing, coding, preparing statistical reports and medico-legal processing, etc., but accruing knowledge on HIM/MR management with regards to “WHAT is this thing we are managing”, “WHY are we keeping this?”, and ”HOW can we contribute to the quality of documentation?”.

From the post Medical information that require documentation in medical records (this link will redirect you to a new tab of your current browser window), I had presented all the necessary requirements about of medical information that require documentation in a medical records which explicitly stated what is to be documented in a medical record and also standards which implicitly indicated  medical information that require documentation in a medical record.

For surgical information that require documentation in a medical record, I have a count of twelve (12) standards – or also as one can say “requirements”, which explicitly state what is to be documented in a medical record. There are no standards that indicate implicitly any necessity for surgical information to be documented in a medical record.

I have tabulated all the 12 requirements in some charts. But before displaying the charts on the 12 requirements, allow me to summarise the perioperative period for a patient scheduled for surgery in the pictorial below. I think this chart below is relevant to understanding the 12 requirements (a larger view of this chart is displayed in a new tab of your current browser window by clicking on this chart).

And now, the charts below (a larger view of each chart is displayed in a new tab of your current window, by clicking on each chart) show the 12 requirements for surgical information.

Slide1SI
I believe, a HIM) / MR practitioner working in a hospital must be knowledgeable enough of the surgical information contents in the medical records in his or her custody and to contribute greatly to their quality. The medical records must contain all of the surgical information as I spoken of above, recorded in them. This condition is regardless of the type of hospital they work at, irrespective if 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

Patient care after surgery is planned and documented

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Another surgical information that goes into the medical record is the postsurgical care plan to surgical patients. A postsurgical care plan is important for discharge planning and future planning are based on medical and nursing care plans after surgery. The Joint Commission International (JCI) Standard ASC.7.4 also emphasises the importance for such a plan through its statement which reads, “Patient care after surgery is planned and documented.”

As each surgical patient’s postsurgical medical and nursing care needs usually differ, immediate postsurgical care is planned and includes medical, nursing, and others as indicated by the patient’s defined needs. The postsurgical care plan which can begin before surgery based on the patient’s assessed needs and condition, includes the level of care, care setting, follow-up monitoring or treatment, and need for medication.



The postoperative phase (which is each surgical patient’s postsurgical care period) continues until the patient is released from the surgeon’s care. When the client is discharged from the postanesthesia care unit (PACU), the surgeon will later decide the next level of care and the care setting for the patient.  The surgeon documents in the postsurgical plan whether the patient goes either directly to an inpatient hospital bed or to the outpatient ambulatory unit for observation or to discharge the patient to the patient’s home.

The postsurgical care plan will also contain information on follow-up monitoring of the postoperative patient’s return to normal (baseline) respiratory function and cardiopulmonary function and the patient is free from signs of a wound infection within 72 hours after surgery.

Postoperative discomforts like pain – which is usually most severe immediately after the patient’s recovery from anaesthesia, postoperative nausea, urinary retention,  postoperative constipation, postoperative flatus all require treatment and need medication. The treatment(s) and medications form part of the postsurgical care plan documentation.

A Health Information Management (HIM) / Medical Records (MR) practitioner will find among the contents of a medical record for a patient who had undergone surgery, a postsurgical plan(s) documented in the patient’s medical record by the responsible surgeon or verified by the responsible surgeon by co-signature on the documented plan entered by the surgeon’s delegate. The nursing postsurgical plan of care and when indicated by the patient’s needs, the postsurgical plan of care provided by others are also documented in the patient’s medical record. These are often documented in the progress notes. However, nursing care plans are not usually filed in the permanent patient record. The date and time for each of the plans of care documented in the patient’s medical record are evidence to verify that each planned care was provided and documentation was done within 24 hours of the surgery.

With this post, I believe I have completed posts on anaesthesia care and surgical care which have explicit reference to surgical documentation in a medical record for a patient who undergoes surgery.

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

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA