Collaboration, and the holistic care of the patient

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

JCI Standard MCI.12 – a policy on the retention time of records, data, and information

Paper-based medical records is the way most public and private hospitals in Malaysia continue to preserve their patient medical records. Existing filing space for the efficient storage of newer medical records is a common problem, and for most Health Information Management (HIM) / Medical Records (MR) practitioners, it is a never-ending battle against overcrowded files and the struggle to find more space.

The need for adequate storage space for newer and older medical records (as you already know, older medical records placed in storage and rarely accessed are called archived records or inactive records) is driven by medical reasons, legal reasons and management reasons.

Medical records must be kept for so long as they are necessary to support patient care in the treatment and management of cases.

The legal documentation reason has heightened the importance of medical record retention (the length of time a hospital for example will maintain an archived record ) from the threat of medical malpractice suits, as patient and their families become more aware of the rights to quality care, and solicitors ever willing to take on medical malpractice suits.

Thus, the medical records must be kept for so long as long as the threat of a medical malpractice suit exists. So if the medical records are necessary for the purpose of a court case, the medical records must be kept until the case is concluded, a process which may take many years. A doctor may be in court as a litigant or a witness. Even as a witness in a case which is heard many years after the events in question, the doctor may need to refer to the original medical records.

Collection of hospital statistics, disease coding, claims processing, communicable disease reporting, incident reporting, morbidity and mortality reviews are some management reasons.

Does this mean that, if at all possible, medical records should be maintained indefinitely?

Given the hospital’s administrative constrains to provide additional space with additional cost implied versus the statutory mandates to maintain medical records for a defined period for legal reasons, the medical reasons, and the management reasons,.a hospital needs a strategic plan for preserving medical records for a definite period of retention.

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The hospital must develop a medical record retention policy and must be guided by its own activities, research and education activities.

This policy will dictate how medical records are to stored (records can be stored on paper, microfilm, magnetic tape, optical disk, or as part of an electronic (or computer) system), where will they be stored, what happens to the medical records that have lapsed the retention period , all of which are guided by statute, regulation, law and guidelines.

I shall refrain from posting the methods of storage of newer and older medical records and the destruction of medical records that have lapsed the retention period, as I intend to only discuss on establishing a hospital retention policy for medical reasons and legal reasons but briefly and discuss a little more the quality assurance reasons.

HIM/MR practitioners already know that medical records serve for the continuity of medical and nursing care while in hospital, and follow-up care. HIM/MR practitioners also know that medical records must be maintained for specific periods for legal reasons and I like to list the relevant statutes, laws and guidelines that prevail in Malaysia :

  1. The statute of limitations, Act 254, cited as the Limitation Act 1953, dated 19 February 1953, is an Act to provide for the limitation of actions and arbitrations (which is the time period during which a person may bring forth a lawsuit including medical malpractice suits), but applies to Peninsular Malaysia only.
      1. Section 6(1) of this Act limits actions in tort to commence not more than six years after the occurrence of the damage and unlike laws in Australia, the United Kingdom and in Singapore, does not contain provisions for the discretionary extension or exclusion of the time limit allowed by law in relation to tort or personal injuries.
      2. Include in the policy if patient is under a legal disability, that the records should be kept for a minimum of 7 years from the date when the patient’s legal disability ceases or the patient’s death, whichever is earlier, as provided for under Section 24(1) of this act.
  2. Act 629, the National Archives Act 2003 (incorporating all amendments up to 1 January 2006), is an Act to provide for the creation, acquisition, custody, preservation, use and management of public archives and public records (records officially received or produced by any public office for the conduct of its affairs or by any public officer or employee of a public office in the course of his official duties and includes the records of any Government enterprise) and for other matters connected therewith.
      1. The National Archives of Malaysia had supported and agreed to a Ministry of Health Malaysia proposal for a uniform medical records retention and disposal schedule for all public hospitals in Malaysia. Through its letter of approval allowable under Section 27 (1) of the Act 629, the National Archives Act 2003, an approval dated 30 November 2006 was released by the National Archives for a comprehensive and standarised medical records retention and disposal schedule for all public hospitals and health facilities in Malaysia.
      2. The retention period for all medical records with the exception of medical records of psychiatric, obstetric and paediatric cases will be retained for a period of seven (7) years from the last date of treatment.
      3. A copy of this approval can be obtained from a Ministry of Health Malaysia Guideline Manual on Medical Records Management published by the Medical Development Division and released through a Director General of Health Malaysia directive No. 17 of 2012 (Pekeliling Ketua Pengarah Kesihatan Bil 17/2010, Garispanduan Pengendalian Dan Pengurusan Rekod Perubatan Pesakit Bagi Hospital-Hospital Dan Institusi Perubatan Kementerian Kesihatan Malaysia, Bahagian Perkembangan Perubatan Kementerian Kesihatan Malaysia, a document in Malay).
      4. The standarised medical records retention and disposal schedule for all public hospitals and health facilities in Malaysia was circulated through a MoH circular MOH/PAK/121.06.(GU), Mac 2007 in March 2007(Jadual Pelupusan Rekod Perubatan, MOH/PAK/121.06.(GU), Mac 2007 – in Malay).
  3. Act 586, Private Healthcare Facilities And Services Act 1998 (incorporating all amendments up to 1 May 2006) is an Act to provide for the regulation and control of private healthcare facilities and services and other health-related facilities and services. Section 107, (2), (f) under ‘Power to make regulations’ requires that the records to be kept of patients and persons treated in the private healthcare facilities or services but does not stipulate a retention policy.
      1. I think such private healthcare facilities or services could however plan for a retention policy for the reasons given in second paragraph of this post.
      2. The same provision of a minimum period of seven (7) years from the last date of treatment for the retention of all medical records with the exception of medical records of psychiatric, obstetric and paediatric cases could b adopted into a private hospital’s retention policy.
      3. Likewise other contents of the medical records retention and disposal schedule for all public hospitals and health facilities in Malaysia could be availed and incorporated into its own private hospital medical records retention policy.
  4. Act 21, this Act cited as the Age of Majority Act 1971 dated 30 April 1971 is an Act to amend and consolidate the law relating to the age of, states under Section (2) that the minority of all males and females shall cease and determine within Malaysia at the age of eighteen years and every such male and female attaining that age shall be of the age of majority.
      1. Since the minimum period for the retention of all medical records with the exception of medical records of psychiatric, obstetric and paediatric cases is seven (7) years from the last date of treatment, then for minors medical records should be retained for another 7 years from the age of majority, that is for 25 years.
  5. The Medical Defence Malaysia Berhad (MDMB) website at http://www.mdm.org.my/articles.php?newsID=2 (clicking on this link will open the website page in a new tab in your current window) presents a page on Medical Records: Preservation And Matters Of Evidence.  MDMB a “not-for-profit” company limited by guarantee, functioning as a mutual medical defence organisation that aims to provide support in areas such as medico-legal counselling and the development of educational resources.

HIM/MR practitioners must also know that if their hospital is in the process for accreditation of a quality program, then the medical records retention policy must be updated, readily available, complete and relevant. In order to be complete and relevant, I would recommend that this policy be jointly developed with the full knowledge and participation of the medical staff  who have contributed to a medical record content.

HIM/MR practitioners would provide secretarial support, coordinate the updating and completion of a up-to-date and revised hospital medical records policy. This policy will be measured against the Joint Commission International (JCI) Standard MCI.12 which states that “The organization has a policy on the retention time of records, data, and information”, if your hospital is on the path to be accredited or is to be re-surveyed for new period of accredited status when adopting the JCI accreditation process.

So if your hospital has a policy on retaining medical (patient clinical) records and other data and information, the retention process provides expected confidentiality and security, and all of your records, data, and information are destroyed appropriately after the retention period, then clearly this policy will comply with the JCI Standard MCI.12, ME 1 to ME 3.

This is not to imply you only rush to comply with JCI compliance (the JCI Standard MCI.12 merely states this requirement to comply with their standards compliance and accreditation status but does not necessarily mandate record retention schedules) but the policy is relevant for all the reasons as I have given above, once again to reiterate federal and local (if any) retention laws, legal requirements, need for continuing patient care and follow-up, research/educational uses, and management uses.

In closing, do take note that a  policy on retention of medical records is meant to serve as a guide on the retention periods for medical records, and do get the help of a legal counsel of your hospital or organisation if you are not sure about the Laws and their interpretations to be included in the policy.

References:
Edna,  KF 1983, Medical Records Management, 7th edn, Physician Records Company, Illiniois, USA

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

Margaret, AS 2003, Health Information Management, 5th edn, Jossey-Bass, San Framsico, USA

World Health Organisation 2006, Medical Records Manual: A Guide for Developing Countries, WHO Regional Office for the Western Pacific, Philippines

Initial medical assessments results in an initial diagnosis

From the earlier post Medical documentation in medical records of initial medical and nursing assessments, I wrote about the initial assessment which includes :

  • an evaluation of the patient’s medical status through a physical examination and health history
  • the psychological assessment determines the patient’s emotional status (for example, if he or she is depressed, fearful, or belligerent and may harm him- or herself or others)
  • gathering social information on a patient’s social, cultural, family, and economic contexts are important factors that can influence his or her response to illness and treatment but is not intended to “classify” patients
  • inputs from patient’s families  providing helpful clues in these areas of assessment and in understanding the patient’s wishes and preferences in the assessment process
  • economic factors as part of the social assessment or assessed separately when the patient and his or her family will be responsible for the cost of all or a portion of the care while an inpatient or following discharge

You would have also read from that post, how many different qualified individuals may be involved in the assessment of a patient. The most important factors are that the assessments are complete and available to those caring for the patient.

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When the initial assessments are completed and available, the doctor forms and initial diagnosis. The initial diagnosis ia an important part of the medical documentation in a medical record.

For quality assurance purposes, and for benefit of a Health Information Management (HIM) / Medical Records (MR) practitioners working in a hosptial that is actively undergoing an accreditation program for quality assurance and if your hospital is adopting the Joint Commission International (JCI)  acrreditation program, do take note that the initial diagnosis is an important medical documentation by a doctor in a medical record and must always be present in a medical record in order to comply with the Joint Commission International (JCI) Standard AOP.1.2, ME 4 which states that “The initial assessment(s) results in an initial diagnosis”.

For your information the JCI Standard AOP.1.2 states that “Each patient’s initial assessment(s) includes an evaluation of physical, psychological, social, and economic factors, including a physical examination and health history.”

Also ensure that all your inpatient and outpatient medical records :

  • contain documentation about an initial assessment(s) that includes a health history and physical examination consistent with the requirements defined in hospital policy,  thus complying with the JCI Standard AOP.1.2, ME 1
  • contain documentation about that each patient had received an initial psychological assessment as indicated by his or her needs, which will then comply with the JCI Standard AOP.1.2, ME 2 ; and
  • contain documentation that shows each patient received an initial social and economic assessment as indicated by his or her needs, which will also then comply with the JCI Standard AOP.1.2, ME 3

In summary, your medical records documentation must comply with the JCI Standard AOP.1.2 and its four (4) requirements, if your hospital hopes to meet this JCI accreditation standard of quality of care.

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

JCI Standard MCI.3 – Communication with Patients and Families, provided in an understandable format and language

Patients can only make informed decisions and participate in the care process if they understand the information provided to them. This includes their follow-up care through information about educational and training resources available from the hospital or from community resources through relationships established by the hospital. Community resources help support continuing health promotion and disease prevention education. This follow-up care information from  the hospital or from established community resources is to meet the patient’s ongoing health needs or to achieve their health goals.

Particular attention is given to the format and language used in communicating with and providing education to patients and families. Patients respond differently to spoken instructions, printed materials, videotapes, demonstrations, and so on. Also, it is important to understand the language preferred.

A written statement appropriate to a patient’s age, understanding, and language posted in a hospital is an example to inform the patient and the family’s responsibility on their rights and to understand their responsibilities in the care process of the patient as an inpatient or registration as an outpatient.

Medicine information leaflets is another example of printed materials, but associated with the distribution of medicines. The format used in medicine information leaflets must take into account the order of information which is presented. This order effect is related to the perceived importance of the information which affects people’s understanding and memory of the information presented. For example, patients are likely to remember better about side effects of medicine administered to them irrespective of its relative position in a medicine leaflet in contrast to instructions on dosage and how to take their medicine, which they ought to remember better. Thus the need for key information about drug administration to be given near to the start of a medicines information leaflet.

Hospitals frequently serve communities with a diverse population. One or more languages spoken by patients in the community serviced by the hospital could be used in a loose-leaf folder or file cards. Translators in your community can help build standardised lists for the most commonly heard languages in your community. Technical terms, slang, or phrases with a double or colloquial meaning should be avoided.

Research has shown that a patient speaking the same native language as the doctor (as well as a nurse of other healthcare provider) has the advantage of greater rapport with a patient. They gave better explanations of treatment. Patients had better understanding of instructions, showed a greater recall and asked questions, and undoubtedly understood printed materials better.

If there are differences in the language used between doctors (as well as a nurse or other healthcare provider) and patients, then family members or interpreters/translators may need to assist with the education or translate materials.

Wherever possible, it is better to use a professional interpreter. A trained interpreter often understands the culture of the person, as well as the language. The skilled interpreter can explain nonverbal cues, in addition to what the patient says.

The interpreter is an invaluable staff resource  rather than a family member, child translator – a child member of the family, should be used only as a last resort especially to communicate important clinical and other information and education, and non-family members.

A hospital could also develop a list of its employees or individuals to contact in the community who speak a second language and are willing to act as translators of printed materials, videotapes, demonstrations, and so on.

Sometimes, a family member or significant other can act as an interpreter. Having a member of the family translate may be inappropriate. It is important for the doctor as well as a nurse or other healthcare provider to recognise the limitations of family members and non-family members when they are used to translate or interpret in overcoming any patient barriers to communication and understanding.

The foregoing paragraphs ensues the compliance with the Joint Commission International (JCI) Standard MCI.3, that is “Patient and family communication and education are provided in an understandable format and language.”

In a hospital that is undergoing the process of accreditation and has adopted the JCI quality standards, then the hospital must comply with providing patient and family communication and education in an understandable format and in an understandable language as I have outlined above. The hospital would therefore satisfy the JCI Standard MCI.3, ME 1 and 2.  If the hospital has a policy and practices to engage professional interpreters rather than using family members as interpreters and translators and ensuring that child translators are only used as last resorts, then the hospital complies with the JCI Standard MCI.3, ME 3.

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

Dianne, B 2007, Health communication Theory and practice, Open University Press, NY, 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

Assessments within 24 hours

Let’s assume that you as a Health Information Management (HIM) / Medical Records (MR) practitioner, work in a hosptial that is actively undergoing an accreditation program for quality assurance, and your hospital is adopting the Joint Commission International (JCI)  acrreditation program.

During the survey process when your hospital is undergoing the  JCI  acrreditation program, surveryors may request a closed medical record review session.

As a HIM / MR practitioner in such a hospital setting, you need to know that  a sample of your medical records will be used for this closed medical records review session, and you must be aware of the reason why those records are reviewed and what the surveyors are looking for in them.

The surveyors will check for compliance on JCI standards, and one of them is the JCI Standard AOP.1.5 as listed in the Closed Medical Records Review Form (i.e JCI Standard AOP.1.5 is one of the JCI standards included in the list of standards in this form).

JCI Standard AOP.1.5 states that “Assessment findings are documented in the patient’s record and readily available to those responsible for the patient’s care.”

The Closed Medical Records Review Form is used to gather and document complainance wth the JCI Standard AOP.1.5 which is one of the JCI standards that require documentation in the patient’s medical record.

If you read about the post Medical documentation in medical records of initial medical and nursing assessments on initial medical and nursing assessments, initial assessments and continuous assessment findings are used throughout the care process to evaluate patient progress and to understand the need for reassessment. If all medical and nursing  assessments from the initial instance and throughout the patient’s stay at the hospital is documented well in the patient’s medical record, then your hospital certainly complies well with the JCI Standard AOP.1.5, ME 1 which states “Assessment findings are documented in the patient’s record.”

If your medical, nursing, and other meaningful assessments are documented well and can be quickly and easily retrieved from the patient’s record or other standardised location and used by those caring for the patient, then the surveyors and certainly your hospital’s management will be happy that your hospital passes the JCI Standard AOP.1.5, ME2 which states “Those caring for the patient can find and retrieve assessments as needed from the patient’s record or other standardized accessible location.”

Doctors and nurses must ensure that the patient’s medical and nursing assessments are documented in the record within the first 24 hours of admission as an inpatient.

This does not preclude the placement of additional, more detailed assessments in separate locations from the patient’s record as long as they remain accessible to those caring for the patient. If this is done within this stipulated time frame, then your hospital also complies with the JCI Standard AOP.1.5, ME 3 and ME 4 which state respectively “Medical assessments are documented in the patient’s record within 24 hours of admission.” and “Nursing assessments are documented in the patient’s record within 24 hours of admission.”

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