Category Archives: Quality

Check your medical record for patient monitoring during anaesthesia

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This saturday weekend evening, I finish a post on one of the six (6) standards for Anaesthesia Care found in the Joint Commission International Accreditation Standards For Hospitals, 4th Edition that requires documentation in the medical record. I have two (2) more remaining standards to write about under Anaesthesia Care. This post is about patient monitoring during anaesthesia.

The overall monitoring during anaesthesia is a continuous process (“continuous” meaning, prolonged without any interruption at any time) mandated by accreditation requirements for example, by the Joint Commission International (JCI) Standard ASC.5.3, as one of the JCI standards that guide the quality improvement program in anaesthesia that apply to all general anaesthetics, regional anaesthetics, and monitored anaesthesia care. JCI Standard ASC.5.3  evaluates the quality of care by attention to the process of monitoring of the patient during anaesthesia. Adequate monitoring is a key factor (Ronald & Manuel, 2011) in the prevention of patient injury related to anaesthesia

Monitoring and maintenance of normal physiology during the perioperioperative period of anaesthetised patients is designed to collect data that reflect the patient’s ongoing physiologic conditions and any responses that may result from therapeutic interventions. Monitoring allows the anaesthesiologist to react to adverse physiologic changes or trends before they result in irreversible damage. Monitoring is deemed (Ronald & Manuel, 2011) to serve to further enhance the vigilance of the anaesthesiologist and decrease the role of human error in anaesthetic morbidity and mortality.

Monitoring methods depend on the patient’s preanaesthesia status, anaesthesia choice, and complexity of the surgical or other procedure performed during anaesthesia.

The vigilance of the anaesthesiologist is enhanced by the use of a monitoring equipment such as the anaesthesia workstation (previously recognised as the anaesthesia machine) which has evolved (Ronald & Manuel, 2011) from a simple pneumatic device to a complex integrated computer controlled multicomponent workstation that includes physiologic monitoring systems (electrocardiogram, arterial blood pressure, temperature, pulse oximeter, and inhaled and exhaled concentrations of oxygen, carbon dioxide, anaesthetic gases, and vapors). The anaesthesia workstation provides objective data to the anaesthesiologist’s own subjective observations.

From my experiences, it is commonly viewed that anaesthesia standards are applicable in whatever setting anaesthesia and/or moderate or deep sedation are used because of the (JCI, 2011) common and complex processes of the administration of anaesthesia during which the patient’s protective reflexes needed for ventilatory functions are at risk.

In the prevention of patient injury related to anaesthesia,  JCI Standard ASC.5.3 or in all cases when the use of  (JCI, 2011) anaesthesia, sedation, and surgical interventions are common at settings which include hospital operating theatres, day surgery or day hospital units, dental and other outpatient clinics, emergency services, intensive care areas, or elsewhere must have a hospital policy and standard operating procedures which address the following issues for anaesthetised patients:

  1. the basic anaesthetic monitoring standards adopted for example from Standards for Basic Anaesthetic Monitoring  by the American Society of Anaesthesiologists, that mandate (Ronald & Manuel, 2011) the use of pulse oximetry, capnography, an oxygen analyzer, disconnect alarms, body temperature measurements, and a visual display of an electrocardiogram (ECG) during the intra-operative period in all patients undergoing anaesthesia.
  2. the minimum frequency, for example systemic blood pressure and heart rate must be evaluated every 5 minutes
  3. the choice of intra-operative monitoring during anaesthesia depends on the patient’s medical condition and the complexity of the intra-operative procedure
  4. the type of anaesthesia is uniform for similar patients receiving similar anaesthesia wherever anaesthesia is provided
  5. the patient’s physiological status assessed immediately after recovery from anaesthesia

The JCI Standard ASC.5.3 requires documentation of monitoring of the patient during administration of anaesthesia. An anaesthesia record is required and must be maintained when a patient receives an anaesthetic other than a local anaesthetic to document patient monitoring during administration of anaesthetic agents and other activities related to the surgical episode (intra-operative anesthesia).

Documentation regarding monitoring of the patient during administration of anaesthesia  in the anaesthesia record includes (Michelle & Mary, 2011) the following records:

  1. anaesthetic agents administered, including amount, technique(s) used, effect on patient, and duration
  2. patient’s vital signs (e.g., temperature, pulse, blood pressure) enhanced by the use of a monitoring equipment such as the anaesthesia workstation
  3. other activities related to the surgical episode like any blood loss, transfusions administered, including dosage and duration, IV fluids administered, including dosage and duration
  4. the patient’s physiological status immediately after recovery from anaesthesia

If your hospital shows the (a) existence of a policy and procedures that address the standards required for the (i) minimum frequency of monitoring, (ii) type of monitoring,  (iii) process of monitoring of the physiological status during the administration of anaesthesia and immediately after recovery from anaesthesia is uniform for similar patients receiving similar anesthesia wherever anesthesia is provided, and when (b) all the results of monitoring during anaesthesia are written into the patient’s anaesthesia record, I think it is safe to conclude that your hospital fully meets the JCI Standard ASC.5.3 and its three (3) Measurable Elements requirements for documentation of monitoring of the patient during administration of anaesthesia.

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

Ronald, DM & Manuel, CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA

Documentation by the surgeon prior to surgery

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Surgery also often called an “operation”, is an invasive process because an incision is made into the body to repair or remove or replace a part of body tissues or organs as the best treatment for his or her disorder.

As surgery always carries a high level of risk, the surgeon will assess each patient and weigh the surgical risk against the need for surgery.

In some cases, surgery must be done despite the high level of risk due to the presence of risk factors, for example the common instance of  patients presenting for surgery with a pre-existing physical disorder risk factor from diabetes mellitus, with slowed healing, increased incidence of infections, insulin imbalances, inability to regulate blood sugar levels.

When a person is brought in by ambulance and must receive immediate surgery, this emergency patient needs emergency surgery. The assessment process for an emergency patient is carried out in a shortened time frame and the surgery performed immediately to save the patient’s life. Examples are ectopic pregnancy with threat of rupture, severe internal hemorrhage, ruptured appendix, and angioplasty after a heart attack.

So in most normal circumstances, patients for which surgery is planned have a medical assessment and all required tests performed before the surgery. Assessment(s) provide information necessary to :

  1. select the appropriate procedure and the optimal time identified from sequencing the assessments in the clinical care path on a timeline for the patient
  2. perform procedures safely
  3. interpret findings of patient monitoring

The selection of an appropriate invasive procedure considers information from the following sources used to develop and to support the planned invasive procedure by the responsible surgeon before the procedure is performed :

  1. the initial medical and nursing assessment(s) on the patient’s history and physical status
  2. available results that have been reported within a time frame to meet the patient needs (in this case the impending surgery) for all required tests, such as electrocardiogram (ECG), ordered laboratory tests, radiology and diagnostic imaging study

The surgical care planned for the patient is documented in the patient’s medical record, more so if the hospital is seeking or plans to continue maintaining accreditation status  dictated by standards from a hospital quality assurance agency like that of the Joint Commission International (JCI). The JCI standard on documentation by the surgeon prior to surgery is the  Standard ASC.7, which states that “Each patient’s surgical care is planned and documented based on the results of the assessment”, requires the surgeon to document the following prior to performing surgery :

  1. procedure selected
  2. a preoperative diagnosis in the Preoperative Note which is a progress note documented by the surgeon prior to surgery, which summarizes the patient’s condition – the name of the surgical procedure alone does not constitute a diagnosis (JCI 2011)

However I think documentation on the surgical care plan should also incorporate the following although they are not mentioned to meet JCI Standard ASC.7 :

  1. emotional support provided to the patient and the family, especially to the patient who faces surgery as the patient may compare the previous experience with this one and can be particularly frightened if the patient has had any previous experience with surgery which was difficult or the patient facing surgery for the first time may be apprehensive about pain, about losing consciousness, fearful of cancer or of being disabled or worse still some others maybe afraid they will die
  2. preparation of the patient physically for surgery for example a surgical preparation or “prep” is done by cleaning the skin with an anti-infective agent and may be shaved when an incision is to be made in the skin
  3. that all legal matters, such as signing the surgical consent (informed consent), are carried out
  4. routine preoperative care provided

JCI does not say where in the medical record the surgical care plan should be documented. From my experiences, these are often documented in the progress notes and are authenticated by the responsible surgeon.

In summary, If documentation is completed as above in the medical record of a patient prior to surgery, then the hospital seeking or planning to continue maintaining accrediation status from JCI,   will fully meet  JCI’s Standard ASC.7 and it’s four (4) measurable elements.

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

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

bRound-ups segment/category post, focus on medical records documentation and quality about Medical and Nursing Care and ongoing posts about Anaesthesia Care and Surgical Care

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This would be the second monthly bRound-ups segment/category post after the last one in early June.

In July, posts about medical information that must documented in a medical record dominated the blog. I rounded up all the medical information that require documentation in medical records and composed about them in the post Medical information that require documentation in medical records (this link will open in a new tab of your current browser window). This post ended all about medical documentation a Health Information Management (HIM) / Medical Records (MR) practitioner must know to ensure the quality of medical records as well to meet the quality standards set by the Joint Commission International (JCI), if his or her hospital is seeking JCI accreditation status or continues maintaining such standards for future surveys.

July was also when I embarked on bringing together posts that relate to anaesthesia and surgical documentation in the medical record.

I started off with my first post related to anaesthesia and surgical documentation in the medical record about the need for a preanesthesia assessment and a separate preinduction assessment performed to re-evaluate patients immediately before the induction of anaesthesia by a qualified individual who conducts a preanesthesia assessment and preinduction assessment for every patient prior to surgery.

More posts follow in August on Anaesthesia Care and Surgical Care from the standards contained in the appropriately named ASC chapter of the 4th Edition Joint Commission International Accreditation Standards For Hospitals, effective 1 January 2011. I do hope to finish covering posts on Anaesthesia Care and Surgical Care by end of August 2012.

In completing these posts on Medical and Nursing Care as well as Anaesthesia Care and Surgical Care, I must confess and I have already confessed in all my previous posts, that I am no expert in Medical and Nursing Care or Anaesthesia Care and Surgical Care. I am only blogging based on my experiences in the healthcare industry and also providing evidence to support my posts from literature review of relevant medical text-books I own or I need to resource from libraries, and of course strictly referring to the 4th Edition Joint Commission International Accreditation Standards For Hospitals, effective 1 January 2011 manual.

Apart from the medical and surgical documentation posts in July, I wanted to cover casemix as well and so I did with one post describing how hospitals in Wales, the United Kingdom used some casemix concepts to bring about efficiency and order to the hospital system there. I do not intend to bring text-book material here but I shall endeavour to relate to text-book content and evaluate real situations when casemix is seen in action.

I did not want to miss out covering topics from time to time on standards  that refer to the Management and Communication of Information (MCI) chapter of the 4th Edition Joint Commission International Accreditation Standards For Hospitals. So the post JCI Standard MCI.16 – Leadership and Planning, records and information are protected (this link will open in a new tab of your current browser window) covered the Standard MCI.16 which requires that “Records and information are protected from loss, destruction, tampering, and unauthorized access or use”.

To the reader, I hope to focus and continue to finish as soon as possible all the standards covering surgical documentation in the medical record by end of August, and also include any interesting and worthy post(s) on any other subject matter, alongside issues of medical record documentation and medical record leadership and planning issues from the MCI chapter as part of my August 2012 postings.

Thank You for reading this blog!

The anaesthesia used and anaesthetic technique are written in the patient record

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The decision-making process necessary for deciding which anaesthesia to use and the anaesthetic technique to select is the responsibility of the anaesthesiologist, the anaesthesia provider (the health professional providing the care) rendering the anaesthetic care planned for the patient related to his or her identified needs.

The anaesthesia care provider has several options deciding which anaesthetic technique (Ronald & Manuel 2011) to select available including (1) general anaesthetic – usually induced in adult patients by the intravenous administration of an anaesthetic (propofol, thiopental, or etomidate) that produces rapid onset of unconsciousness, (2) regional anaesthetic – spinal (Spinal anaesthesia is accomplished by injecting local anaesthetic solution into the cerebrospinal fluid (CSF) contained within the subarachnoid (intrathecal) space. or epidural (achieved by injection of local anaesthetic solution into the space that lies within the vertebral canal but outside or superficial to the dural sac) or caudal anaesthesia (represents a special type of epidural anaesthesia in which local anaesthetic solution is injected into the caudal epidural space through a needle introduced through the sacral hiatus) are selected when maintenance of consciousness during surgery is desirable, (3) peripheral nerve block – a technique of anaesthesia for superficial operations on the extremities or (4) monitored anaesthetic care (MAC) – a procedure in which an anaesthetic provider is requested or required to provide anaesthetic services, which include preoperative evaluation, care during the procedure, and management after the procedure.

I shall avoid details of the types of the anaesthesia used and the anaesthetic techniques (I have already given enough extracted text-book explanations in the paragraph above of anaesthetic techniques) used. as I think it is only appropriate for me to highlight in this post what needs to be satisfied by a quality assurance requirement, for example the Joint Commission International (JCI) quality Standard ASC.5.2 which requires that “The anaesthesia used and aesthetic technique are written in the patient record.”

It is clear from the intent of this standard that JCI surveyors must be able to find evidence of  the anaesthesia used and anaesthetic technique written somewhere in the patient’s medical  record during a hospital survey process.  The Health Information Management (HIM) / Medical Records (MR) practitioner’s role should be ensure that he or she can identify the location of this evidence in the medical record and contribute to completeness and quality of the medical record.

Anaesthesia providers qualified to administer anaesthesia like an anaesthesiologist, documents patient monitoring when a patient receives an anaesthetic other than a local and other activities related to the surgical episode. Detailed records of the course of anaesthesia are documented in an anaesthesia record, the piece of evidence of the anaesthesia used and anaesthetic techniques used. Preoperative and postoperative visits, and detailed records of the course of anaesthesia, serve as the best protection for the anaesthesiologist or other authorised anaesthetic provider against medico legal action.

Contents of the anaesthesia record in the usual handwritten anaesthetic record documenting the anaesthesia used and the anaesthetic technique used contain adequate information (Michelle & Mary 2011) and  justify the anaesthesia care as follows:

  1. Preanesthesia medication administered, including time, dosage, and effect on patient
  2. Appraisal of any changes in the patient’s condition (since preanesthesia evaluation)
  3. Anaesthesia agent administered, including amount, technique(s) used, effect on patient, and duration, qualifying for full compliance against ME 1 and ME 2 requirements for JCI Standard ASC.5.2
  4. Patient’s vital signs (e.g., temperature, pulse, blood pressure)
  5. Any blood loss
  6. Transfusions administered, including dosage and duration IV fluids administered, including dosage and duration
  7. Patient’s condition throughout surgery, including pertinent or unusual events during induction of, maintenance of, and emergence from anaesthesia.
  8. Authentication by the individual qualified to administer anaesthesia (e.g., certified registered nurse anaesthetist, anaesthesiologist) and names of anaesthesia assistants identified in the patient’s anesthesia record, would then serve to satisfy full compliance with the ME 3 for Standard ASC.5.2

Here is a part of an anaesthesia record (as below) showing the fields for recording anaesthetic technique and anaesthesia agents used (click on the image for a larger view in a new tab of your current browser window).

Source :Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, pg 163

Do take note that preanaesthesia and postanaesthesia evaluation progress notes are sometimes documented on a special form located on the reverse side of the anaesthesia record.

HIM/MR practitioners should also ensure that the medical record contains all records of previous admissions. This is important when an anaesthesia record of a previous surgery which contains historical information, could yield much useful information for the anaesthesia provider especially in the ease of airway management techniques such as direct laryngoscopy when the physical examination by the anaesthesia provider suggests some risk factors for difficult tracheal intubation. If the historical information from the anaesthesia record of this previous surgery clearly documented uncomplicated direct laryngoscopy for a recent surgery, the anaesthesia provider may then proceed with routine laryngoscopy. .

In conclusion, I think the presence of an completed anaesthetic record in a medical record documenting the anaesthesia used and anaesthetic technique, is sufficient evidence to justify full compliance with JCI Standard ASC.5.2

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

Ronald, DM & Manuel, CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA

JCI Standard MCI.13 – Use of standardised diagnosis codes, procedure codes and definitions

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As a Health Information Management (HIM) / Medical Records (MR) practitioner, you will be very familiar with data collected in manual forms and in electronic systems along with the clinical and medical terms the care providers use  in your hospital to document the patient care.

To go on with the Joint Commission International (JCI) Standard MCI.13 from my previous post JCI Standard MCI.13 – Use of standardised symbols and abbreviations (this link will open in a new tab of your current browser window), I think you need to know a little introduction about data since you will be part of the Management of Communications and Information Committee discussing along side with a representative from the hospital Information Technology (IT) department. The Joint Commission International (JCI) Standard MCI.13 does not specify a need to know about data elements and the workings of a Hospital Information System (HIS).

A piece of data that you encounter each day is the data element, which is a basic unit of information collected about anything of interest – for example, a pharmaceutical name or the city in which a patient lives. All the data elements reside in a data dictionary which is a collection of data element and their definitions. The data set refers to a commonly agreed upon collection of data elements found in your HIS and is a standard method for collecting and reporting these individual data elements. The data set used for collection and reporting purposes depends on patient type, for example a data set for oncology (study of cancer) when data is collected on cancers in acute care hospitals and reported to a national cancer registry nationwide.

What a HIM/MR practitioner does need to know that concerns this standard is about what is a medical vocabulary, medical nomenclatures, and classification systems.

A nomenclature is a systematic listing of the proper names. When health care providers document patient care they use a medical nomenclature, for example the Systematized Nomenclature of Medicine (SNOMED) which is a vocabulary of clinical and medical terms (e.g., myocardial infarction, diabetes mellitus, appendectomy, and so on), is used in more than 40 countries (Prathibha 2010).

Medical vocabulary is a system of disease names with explanations of their meanings. A medical coding system (or medical classification system) then organises the clinical and medical terms in a medical vocabulary (the medical nomenclature) into categories according to similar conditions, diseases, procedures, and services and establishes codes (numeric and alphanumeric characters) for each.

Several medical classification systems exist, of which any HIM/MR practitioner  would be most familiar with is ICD-10, which is entitled the International Statistical Classification of Diseases and Related Health Problems (ICD-10). While most WHO member states had started to adopt ICD-10 by 1994, the health care system in the United States continues to use the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) as its official system of assigning codes to diagnoses and procedures related to hospital use. Also in the U.S., ICD-10-PCS, a procedural classification system is intended to replace ICD-9 volume 3 for reporting of inpatient procedures while Current Procedural Terminology (CPT) is still used for all outpatient procedures.

Diagnoses and procedures codes are reported to third-party payers for reimbursement as in the U.S., to external agencies for data collection, and internally for education and research in most countries. Standard terminology enables data capture to proceed in a structured manner, facilitating the collection of information and enhancing the ability to perform data analyses.

Your hospital will be checked for compliance to this standard and hopefully your hospital is prepared to fully meet the four (4) measurable elements of JCI Standard MCI.13 which measure if (i) only standardised diagnosis codes and procedure codes for example ICD-10 or ICD-10 PCS are used and monitored, and (ii) standardised definitions, symbols,  and abbreviations are used and their usage monitored but (iii) ensuring that those symbols and abbreviations not to be used are identified and monitored as well.

Potential sources of errors at each step of the disease coding process using standardised diagnosis codes and procedure codes must be monitored by the HIM/MR department during routine and/or random checks of medical records to ensure code accuracy. Increased attention  to monitoring code accuracy is important as it directly impacts the quality of decisions that are based on codes as a result of the application of ICD codes for purposes other than those for which the classifications were originally designed as well as because of the widespread use for making important funding for example casemix, clinical, and research decisions.

Standardised definitions, symbols, and abbreviations use – taking into account those symbols and abbreviations that are not to be used (that is the Do Not Use List) must be monitored as  I posted in my previous post JCI Standard MCI.13 – Use of standardised symbols and abbreviations (this link will open in a new tab of your current browser window).

A hospital must also ensure that standardisation of diagnosis codes and procedure codes, definitions, symbols,  and abbreviations usage is consistent with recognised local and national standards and even international standards and best practices.

With this post, I think I briefly blogged about the implications of JCI Standard MCI.13 and your role as a HIM/MR practitioner in ensuring compliance to this standard.

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