Category Archives: Hospital Accreditation

JCI Standard MCI.19.4 – Patient Clinical Record, the “quality oversight mechanism“

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It is a common sight in hospitals as doctors and nurses make their rounds assessing patient needs and providing care. It is not uncommon as managers, support staff like HIM/MR professionals, and others in a hospital also make their rounds around their tasks assessing processes and resources and exercise set professional standards to their daily work, thereby understanding how processes can be more efficient, how resources can be used more wisely, and physical risks(safety) to the patients and staff can be reduced.

Thus, quality and safety is entrenched in the needs and care of patients as individual health care professionals and other staff execute their daily work.

As these individual health care professionals and other staff go about their daily work, the organisation continuously plans, designs, measures, analyses, and improves clinical and managerial processes to achieve maximum benefit from its quality and safety efforts.

It is no doubt to my mind that all these efforts to get quality and safety measures well organised requires no less clear leadership, needs some kind of mechanism and an organisational framework to oversee and improve those processes. As most clinical care processes, managerial processes and quality issues are interrelated and involve more than one department or unit and may involve many individual jobs, accentuates the need for clear leadership, a mechanism to work around with the help of an organisational framework for quality and safety.

This framework will develop greater leadership support for an organisation wide program, train and involve more staff, set clearer priorities for what to measure, base decisions on measurement data, and make improvements based on comparison to other organisations, nationally and internationally.

The framework and the mechanism to guide quality improvement and patient safety efforts in a hospital rest with a quality improvement and patient safety oversight group or committee.

All of the above explains  the “quality oversight mechanism“ I talked about in the post JCI Standard MCI.19.4 – Patient Clinical Record.

Abridged, and adapted from Quality Improvement and Patient Safety (QPS), Governance, Leadership, and Direction (GLD), and Management of Communication and Information (MCI) chapters of the JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 4th Edition

JCI Standard MCI.19.4 – Patient Clinical Record

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With this post, it is the finish line for the relevant standards that apply to the Patient Clinical Record expounded from the JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 4th Edition.

But the finish line is not quite over.

This last standard that applies to the Patient Clinical Record (PCR), Standard MCI.19.4 states that “As part of its performance improvement activities, the organization regularly assesses patient clinical record content and the completeness of patient clinical records”.

Here I present a Q&A format to review this standard.

  How often does a hospital assess its PCRs?
  PCRs are to be reviewed on a regular basis, measureable by ME 1.
  Do you review all PCRs in the hospital?
  NO, the review  “uses a representative sample”, measureable by ME2. It is important to ensure that this representative sample includes “records of active and discharged patients” as will be accessed for compliance by ME6. In my next post for this standard, I shall elaborate more on this process, for example on how I conducted the selection of the representative sample.
  Who conducts this review?
  “The review is conducted by physicians, nurses, and others authorized to make entries in patient records or to manage patient records”, measureable by ME 3.
  What is the objective of this review?
  “The review focuses on the timeliness, legibility, and completeness of the clinical record” ”, measureable by ME 4. You would have read the post regarding “the timeliness, legibility, and completeness of the clinical record “from the post JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record
  Is anything else checked in the review process?
  “Record contents required by laws or regulations are included in the review process”, measureable by ME 5. In Malaysia, neither specific laws nor regulations govern records contents. Guideline exist, I did post about the MMC guideline for medical records contents from the post Malaysian Medical Council (MMC) – acceptable contents of a patient’s medical record
  How are the results of this review process utilised by a hospital?
  “The results of the review process are incorporated into the organization’s quality oversight mechanism”, measureable by ME 7. 

More on the “quality oversight mechanism“, and also on a future post, how as the JCI MCI Champion1, I prepared the results of the review in a comprehensive report for management.

1A staff selected by management to spearhead all related activities to a specific chapter or chapters from the JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS.

Malaysian Medical Council (MMC) – acceptable contents of a patient’s medical record

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Further to the acceptable norm for medical record contents, and qualified by the JCI Standard MCI.19.1 which states that “The patient clinical record contains sufficient information to identify the patient, to support the diagnosis, to justify the treatment, to document the course and results of treatment, and to promote continuity of care among health care practitioners”, HIM/MR practitioners in Malaysia need to take note that the Malaysian Medical Council (MMC) recommends  the following items which may make up the contents of a patient’s medical record – perhaps other countries also have similar guidelines :

  • Doctor’s clinical notes
  • Recording of discussion with patient/next of kin regarding
    disease/management/possible use of tape recording for such discussions
  • Referral notes to other specialists for consultation/co-management
  • Laboratory reports
  • Imaging records and reports
  • Clinical photographs
  • Drug prescriptions
  • Nurses’ reports
  • Consent forms
  • Operation notes/anaesthetic notes
  • Video recordings
  • Printouts from monitoring equipment
  • Correspondence with other healthcare professionals
  • Computerised/electronic records
  • Recordings of telephone consultations.

Source: mmc.gov.my/v1/

JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record

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Its been 7 days since I last posted on quality standards for patient clinical records.

To continue on JCI hospital accreditation standards, this Thursday morning I am posting away this post drafted over the last 4 days, sharing with you my experiences on the JCI Standard MCI.19.2 and JCI Standard MCI.19.3. These 2 standards relate to the quality of patient clinical records.

JCI Standard MCI.19.2 states that “organization policy identifies those authorized to make entries in the patient clinical record and determines the record’s content and format”.

Thus, the person(s) who have the authority and right to document in a patient clinical record must be as defined by the hospital’s policy. This would mean all writers who document in a patient clinical record – doctors especially, must be trained in and/or briefed and follow their hospital’s standards and policies for documentation.

A hospital policy for patient record documentation must define by job title and function, including students in academic settings as those authorised to make entries in the patient clinical record The policy must determine the format and location of entries, contain a process to ensure that only authorised individuals make entries in patient clinical records, contain a process that addresses how entries in the patient record are corrected or overwritten, provides identities of those authorised to have access to the patient clinical record and thereby have the obligation to keep the information confidential, and also contains a process to ensure that only authorised individuals have access to the patient clinical record and if information is compromised then it also contains a  process to be followed when confidentiality and security are violated. If your hospital policy satisfies these provisions, then the MEs of MCI19.2 surely be in full compliance (graphic below gives a summary of the policy, double-click on graphic for a larger view of this graphic in a new tab, of the same window of your browser).

In Malaysia, training and awareness on the right to document in patient clinical records by doctors begins during their internship. “A Guidebook for House Officers”, published 23 April 2008 by the Malaysian Medical Council, clearly states that “in Malaysia, pursuant to the Medical Act 1971, internship is only imposed upon after graduation. The two-year internship combines service and training roles. It is formulated in such a way to ensure medical practitioners like you gain appropriate knowledge, skill and experience as well as correct attitude rather than merely employment and provision of services”. This training roles includes that regarding documentation in the patient clinical record as in section 4.4, page 32 of this guidebook.

If the author, the date and the time for each patient clinical record entry especially for timed treatments or medication orders can all be identified successfully, then you patient record satisfies the Standard MCI.19.3 which states that “every patient clinical record entry identifies its author and when the entry was made in the record”.

However the requirement that the author, the date and the time for each patient clinical record entry especially for timed treatments or medication orders, must be stipulated in the hospital policy.

I think it is also wise to include in the policy that the authors should sign with their legal signature (your last name and legal first name or initials), no nicknames should be used, and initials should follow their name indicating their status as a specific caregiver, depending on local statutes and regulations which I think is lacking in Malaysia, but take note that this is not required(no mention) by JCI Standard MCI.19.3

I did not cover in this post about counter-signatures, telephone order (T.O.), voice order (V.O.), Fax Signatures, Electronic Signatures, and Signature Stamps, but of course all these other modes of documentation entries can be included in the policy.

Here I remember the familiar ISO 9001 cliché “say what you do and do what you say”, is to document everything that everyone does. You also must have heard the “wasn’t documented, wasn’t done” motto which is a common one in healthcare settings.

JCI MCI19.1 & MCI19.1.1 – Patient Clinical Record

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The Standard MCI.19.1 states “The clinical record contains sufficient information to identify the patient, to support the diagnosis, to justify the treatment, to document the course and results of treatment, and to promote continuity of care among health care practitioners” , while the Standard (sub-standard) MCI.19.1.1 states that “The clinical record of every patient receiving emergency care includes the time of arrival, the conclusions at
termination of treatment, the patient’s condition at discharge, and follow-up care instructions”.

The clinical record is only complete and can satisfy the above standards if your hospital has implemented a standarised medical record format and content of a patient’s clinical record to help promote the integration and continuity of care among the various practitioners of care to the patient.

Let us now view as below the standards, their respective MEs, and how I suggest (my suggestions in brown) each of these MEs can meet full compliance for these two standards (double-click on each of the following images BELOW for a larger view of each image which will then display in a new tab of the current window of your browser) :

NOTE: With the exception of MCI.19.1 and MCI.19.1, all the other standards in this post refer to other forms of entries in the patient clinical record.