Category Archives: Quality

Medical Records and the continuum of care

Posted on by
Reply

The individual responsible for the coordination of the patient’s care must be identifiable and available through all phases of inpatient care as the patient moves through a hospital from admission to discharge or transfer, several departments and services and many different health care practitioners who may be involved in providing care. Thus if a patient Nancy is under constant professional supervision, making handoffs efficient and accurate and this creates continuity throughout Nancy’s care. Since she is always in contact with trained staff, any new information regarding her behaviour will be properly notated and added to her medical records file.

In the United States, the National Quality Forum had identified in a 2006 report (Barbara 2011 p.72) the practice of information management in the medical record to document the continuity of care to matching healthcare needs with service capability, as one of the 30 safe practices that basically helps to create and sustain a culture of safety with the eventual goal “to improve the things that help and prevent the things that harm”.

In fact, the continuity of care (or continuum of care) is among a list of indicators (Judith, H and Paul, D 2009) including access, effectiveness, communication and participation, care and physical comfort, human needs, efficiency, information, and involvement of family and friends on quality care as identified by consumers (patients) who prefer holistic health care and published by the Picker Institute in Europe.

The opportunity to assess continuity of care issues to “trace” the care experiences that a patient had during his or her stay in the hospital is often used in the individual patient tracer activity conducted during the on-site survey under Tracer methodology, which is an evaluation method used to analyse a hospital’s system of providing care, treatment, and services using actual patients as the framework for assessing a hospital’s Joint Commission International (JCI) international standards compliance, i.e a hospital which is already accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status. The medical records of patients currently receiving care in the unit/setting are often used in such evaluations.

As continuity of care is a critical component of patient safety, Health Information Management (HIM) / Medical Records (MR) practitioners must be able to identify who is the responsible individual expected to provide documentation related to the patient’s plan of care because this individual is usually identified in the patient’s medical record or in another manner made known to the hospital’s staff, for example a list of doctors and their specimen signatures.

HIM / MR practitioners are expected to know that this single individual may be a doctor or other qualified individual who has the overall responsibility for coordination and continuity of the patient’s care or particular phase of the patient’s care. This individual is or was providing the oversight of care for a patient during the entire hospital stay which will improve continuity, coordination, patient satisfaction, quality, and potentially the outcomes and thus is desirable for certain complex patients and others in the hospital.

Patients may be delivered in a wide range of community and hospital-based settings and moved from one phase of care to another (for example, from surgical to rehabilitation). The ability to share information between these settings may be limited and fragmented, as a result what usually happens is delays in care when health care providers who are poorly informed ‘reinvent the wheel’ and begin to duplicate procedures and investigations. If the individual originally responsible for the patient’s care continues to oversee all the patient’s care, then a reduction in the quality of care will not be likely nor will it impair continuity of patient care or threaten the patient’s safety. But if this individual originally responsible for the patient’s care changes, this individual would need to collaborate and needs to communicate with the other health care practitioners.

What if the patient goes to multiple doctors in multiple settings that do not have an integrated information system when the health care delivery organisation cannot provide coordination and continuity? I think a patient can take charge of his or her data although it is a challenging responsibility, and so I would advocate and believe that the personal health records approach can bring together a patient’s health information.

If you are a HIM / MR practitioner practising at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then beware that the JCI Standard ACC.2.1 which states that “During all phases of inpatient care, there is a qualified individual identified as responsible for the patient’s care.”

This will require you to:

  1. be aware that the process of continuity of care according to Michelle and Mary (2011, p.71) includes “documentation of patient care services so that others who treat the patient have a source of information from which to base additional care and treatment”
  2. be able to identify from the medical record the individual responsible for the coordination of the patient’s care through all phases of inpatient care had duly provided documentation in the clinical record related to the patient’s plan of care
  3. maintain a list of individuals who are qualified to assume responsibility for the patient’s care and who can be identified to the hospital’s staff by using a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries; I had covered on this aspect in the post JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record
    (this link will open in a new tab of your current browser window)
  4. be aware that other consultants, on-call doctors, locum tenets, or others take responsibility of the patient as identified in a hospital policy that identifies the process for the transfer of responsibility from the responsible individual to another individual during vacations, holidays, and other periods and they assume this responsibility when they duly document their participation/coverage in the medical record
  5. be aware that the JCI Standard ACC.2.1 is included in the Medical Records Review Tool

References:

  1. Barbara JY (ed.) 2011, Principles of risk management and patient safety, Jones & Bartlett Learning, Sudbury, MA, USA
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA
  4. Judith, H and Paul, D (eds.) 2009, Patient Safety First Responsive Regulation In Health Care, Allen & Unwin, New South Wales, Australia
  5. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Wait times documentation in the medical record

Posted on by
Reply
Cartoon credit: theragblog.blogspot.com/

Cartoon credit: theragblog.blogspot.com/

Health Information Management (HIM) / Medical Records (MR) practitioners maybe unaware of information documented in the patient’s medical record when inpatients and outpatients seeking care and/or diagnostic services patients, undergo long waiting periods for diagnostic and/or treatment services or when obtaining the planned care may require placement on a waiting list.

The issue of waiting periods for healthcare may be described from the study by Singh et al. (2010) as patient-related i.e delays referring to the time period from the onset of symptoms to the patient’s seeking of medical advice or health system-related. Singh et al. (2010) define health system delays to the time period from the first contact of the patient with the health care system to definitive treatment, which may also include delays in patient access to first contact. Singh et al (2010) further categorised health system delays into diagnostic delays defined as time from the patient’s first contact with the health care system to diagnosis and treatment delays as time from diagnosis to definitive treatment.

HIM / MR practitioners practising at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, must be aware that the JCI Standard ACC.1.1.3 which states that “The organization considers the clinical needs of patients when there are waiting periods or delays for diagnostic and/or treatment services.” which requires the aforesaid reasons and alternatives on waiting periods to be duly documented in the patient’s medical record and this requirement applies to:

  1. inpatient and outpatient care and/or diagnostic services
  2. does not include minor waits in providing outpatient care or inpatient care, such as when a doctor is behind schedule
  3. does not apply for oncology cases or transplant cases 

To this end, HIM / MR practitioners must:

  1. be able to locate information recorded in the patient’s medical record that will contain the associated reasons for the delay or wait and available alternatives consistent with their clinical needs;
  2. must be aware that the JCI Standard ACC.1.1.3 is included in the Medical Records Review Tool; and
  3. include this requirement in HIM / MR written policies and/or procedures to support consistent practice.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Singh, H, Coster, DC, Shu, E,  Fradette, K, Latosinksy, S, Pitz, M, Cheang, M & Turner, D 2010, Wait times from presentation to treatment for colorectal cancer: A population-based study, Canadian Journal of Gastroenterology, vol. 24, no. 1, pp. 33–39, viewed 2 July 2013, < http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2830632/#__ffn_sectitle>

JCI Standard MCI.7 – Medical Records contents sharing

Posted on by
Reply

Medical Records continue to be a primary source of information containing patient-specific information to provide effective care, develop treatment guidelines, determine ability to pay for care, bill third-party payers, and anonymously conduct research studies. Any hospital must maintain a medical record for each inpatient and outpatient. It needs to be available during inpatient care, for outpatient visits, and at other times as needed and it must be up to date to ensure communication of the latest information. Thus, the medical record containing medical, nursing and other patient care notes is an essential communication tool that is useful to support the continuity of the patient’s care and must always be available so that it can be shared among all of the patient’s health care practitioners at all times.

Since the Medical Record is always available to all the patient’s health care practitioners, a hospital must create written privacy policies and procedures, which clarify who has the right to access protected information, how protected information will be used within the covered entity, when protected information may be disclosed, and employees must be trained on such privacy policies and procedures to ensure confidentiality of patient information.

An example when written privacy policies and procedures must be created is epitomized  in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in the United States of America.

Electronic Medical Records (EMR) like paper based medical records, must also be available to all the patient’s health care practitioners. In order to maintain patient confidentiality, the patient’s health care practitioners must be granted need-to-know status to gain access to the EMR. However there are exceptions, like when attending and resident doctors who are involved in current treatment episodes or on an emergency basis can also gain access through a security override feature incorporated into the EMR system.

It is very important that when all of the patient’s health care practitioners and/or other employee or medical staff member are granted access to the EMR, he or she receives training on system security, appropriate access to and utilisation of patient information, password protection features, existence of audit trails and access monitoring, and consequences of inappropriate access and/or most importantly, breach of patient confidentiality.

Many hospitals also require that their employees and medical staff members sign a statement indicating that they understand the confidential nature of patient information and the need to keep the information and their password secure.

Thus, every hospital must, regardless of its level of computerisation, need to have a comprehensive information security policy which defines the hospital’s commitment to confidentiality for patients, members of the community and its employees. It provides a blueprint for defining standards and procedures and it establishes a standard of care with respect to the handling of its confidential informational resources. A confidentiality committee with the task of developing a comprehensive information security policy should be appointed by the hospital’s leaders.

The issue of confidentiality is so important so much so that a preprinted confidentiality statement on the outside of the medical records file folder usually alerts users that patient information in the medical record is confidential and cannot be removed from the facility without proper authority.

If you are a Health Information Management (HIM) / Medical Records (MR) practitioner practising at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then he or she must be aware that the JCI Standard MCI.7 requires that “The patient’s record(s) is available to the health care practitioners to facilitate the communication of essential information.”

In all instances, the HIM / MR department at any type of hospital is responsible for allowing appropriate access to patient information in support of clinical practice, health services, and medical research, while at the same time maintaining confidentiality of patient and provider data.

This is also true when the  HIM / MR department at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, is responsible to collect medical records selected and for allowing appropriate access to patient information in support of a Medical Records Review session.

To end, HIM / MR practitioners  please take note that the JCI Standard MCI.7 is among the five (5) JCI MCI standards within the Communication Between Practitioners Within and Outside of the Organisation block of the JCI MCI Chapter.

References:

  1. Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
  4. Neil, SS (ed.) 2011, Electronic Medical Records A Practical Guide for Primary Care, Humana Press, New York, USA

Nutrition therapy and the medical record

Posted on by
2

Patients are screened for nutritional risk as part of the initial assessment with the application of screening criteria to gather information on nutritional status or functional status – often done by nurses, which must also be completed routinely within 24 hours of admission to the hospital or at an earlier time period.

I had covered at length on this requirement as you can follow from the posts (each of the following links will open in a separate new tab of your current browser window) Hospital screening criteria data to identify patients with nutritional or functional needs and 6 steps in documenting hospital screening to identity patients with nutritional or functional needs.

A patient identified with nutritional or functional needs i.e. at nutrition risk, is referred to a nutritionist for further assessment and a collaborate plan for nutrition therapy is carried out by doctors, nurses, and the dietetics service, and when appropriate with the help of the patient’s family. The nutritionist monitors at intervals the patient’s progress from the nutrition therapy, the nutritionist’s reassessment throughout this special care process is part of all reassessment by all the patient’s health care practitioners as the key to understanding whether care decisions are appropriate and effective, and records the progress in the patient’s record.

So what is nutrition therapy?

A patient is after a burn or surgery. Another patient is with a high fever, or suffering from acute diarrhoea. Yet another patient is with diabetes mellitus, a disorder throughout life. One other patient is suffering an acute illness with coronary or vascular disorders.

Nutrition is a vital component of therapy for the above listed disorders. According to (eds. Catherine, Benjamin, Robert, Katherine, & Thomas 2014, p. 1162), “use of the term therapy recognizes the role of nutrition in affecting patient outcome and acknowledges the demonstrable risks and benefits to nutrition intervention in both the short term and the long term.”

So, nutrition therapy is required with a high protein intake to rebuild, repair and heal body tissues after a burn or surgery. Nutrition therapy is provided when a patient needs fluids and electrolytes to replace what is being lost due to haemorrhaging, vomiting, and perspiring profusely. Because most serum glucose depends on dietary intake, nutrition therapy is a vital component in the prevention and management of diabetes mellitus which necessitates a special diet plan. Nutrition therapy  is again necessary with a special diet limiting or modifying the fat and sodium intake for a patient with coronary or vascular disorders.

Thus, Health Information Management (HIM) / Medical Records (MR) practitioners will find within medical records, progress notes with the nutritional care of the patient met in accordance with the doctor’s orders which includes the nutrition therapy, and the patient’s progress from the nutrition therapy documented by the nutritionist.

I think medical records will only be complete if a patient at nutrition risk undergoing nutrition therapy has his or her medical record showing progress notes from the nutrition therapy documented by the nutritionist. This particular instance of medical record completeness must be satisfied irrespective of your type of hospital, either it is or it is not already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, but if it is, then your hospital will need to comply with JCI Standard COP.5 which requires that “Patients at nutrition risk receive nutrition therapy.”

If JCI Standard COP.5 and its four (4) Measurable Elements are complied satisfactorily, then your medical record also complies with the JCI Standard MCI.19.1 which states that “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.”

Before I end, some of you may be wondering what’s the difference between a dietitian and a nutritionist? I am not going to elaborate much on this but since I have used the terms dietitian and nutritionist in three related posts on nutrition,  I know for certain that dietitians and nutritionists are both food and nutrition experts respectively. You may find out more on dietitians and nutritionists from the Academy of Nutrition and Dietetics (United States) and from the University of Maryland Medical Center, United States. Some say dietitians are considered to be nutritionists, but not all nutritionists are dietitians.

References:

  1. Catherine, AR, Benjamin, C, Robert, JC, Katherine, LT & Thomas, LT (eds.) 2014,  Modern nutrition in health and disease, 11th ed, Lippincott Williams & Wilkins, Philadelphia, USA
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Sylvia, ES 2012, Nutrition and diagnosis-related care, 7th edn, Lippincott Williams & Wilkins, Philadelphia, USA

Impossible for a hospital to collect data to measure everything it wants

Posted on by
Reply

It is impossible for a hospital to collect data to measure everything it wants due to its limited resources.  Thus, while a hospital may desire to choose which ever clinical processes and outcomes are most important, but I think it is a prerequisite that any hospital must collect data to measure the managerial processes and outcomes which relates to patient demographics and clinical diagnoses based on its mission, patient needs, and services.

The process, procedure, or outcome to be measured for the managerial area which relates to patient demographics and clinical diagnoses is one of the nine managerial measures recommended by the Joint Commission International (JCI) as outlined under the JCI Standard QPS.3.2 which states that “The organization’s leaders identify key measures for each of the organization’s managerial structures, processes, and outcomes.”

The subject of process, procedure and outcome reminds me of the Three Core Process Model, which groups the many processes that take place in any hospital into three core categories: (1) clinical processes, (2) operational or patient flow processes, and (3) administrative processes.

I shall focus on operational or patient flow processes, and administrative processes which concern the managerial processes and outcomes which relates to patient demographics and clinical diagnoses.

Health Information Management (HIM) / Medical Records (MR) practitioners will be familiar with the standardised operational or patient flow processes which includes processes that typically start with registering and admitting of patients during their visit to the hospital or in the course of their stay in the hospital that enable them to access the clinical processes related to diagnosis, treatment, prevention, and palliative care to address their clinical needs. An operational/patient flow process is an example of a managerial process which utilises and collects patient demographics data during the processes available and familiar to HIM / MR  practitioners when:

  1. admitting inpatients for care
  2. for registering outpatients for services
  3. admission directly from the emergency service to an inpatient unit
  4. the process for holding patients for observation in the Emergency department (ED)
  5. how patients are managed when inpatient facilities (beds and/or services) are limited
  6. how patients are managed when no space is available due to ED crowding and high hospital occupancy rates, thereby creating temporary inpatient holding areas (boarding patients) before admitting patients or to admit patients to the appropriate unit

The administrative decision-making core processes occupy two positions in The Three Core Process Model, one above clinical processes and the other below operational or patient flow processes. Decision making, communication, resource allocation, and performance evaluation processes make up the administrative decision-making core processes. These processes are definitely not under the domain of HIM / MR  practitioners, but HIM / MR  practitioners do contribute to administrative decision-making core processes by the hospital’s leaders by providing data, e.g bed statistics for resource allocation, participating in performance evaluation processes from e.g. Medical Records Review data analysis, uniform use of diagnosis and in the procedure codes based on patient record documentation which supports data aggregation and analysis as well implementation of diagnosis-related groups (DRGs) for decision making processes, and when they communicate with care providers about documentation and compliance issues related to the appropriate assignment of diagnosis and procedure codes.

HIM / MR  practitioners will be aware of prevailing mandatory local, national and international guidelines, standards and norms to measure processes related to patient demographics and clinical diagnoses. Nonetheless a hospital’s leaders are finally responsible for making the final selection of targeted measurement activities. The hospital’s leaders will decide and determine the following:

  1. identify the process, procedure, or outcome to be measured
  2. the availability of “science” or “evidence” supporting the measure to reduce unwanted variation in outcomes
  3. how the measurement will be accomplished by deciding the frequency of measurement
  4. how to organise the measurement activities so as to incorporate data collection into daily work processes

Hospital leaders are busy attending to both operating and strategic-level issues that concern quality, but they usually and always put patients first, and they will use data and information to examine and respond to problems, and rely on the participation of the entire workforce including HIM / MR  practitioners as members of the team who must possess a thorough understanding of the processes and the knowledge of specific tools to assess and to improve processes including those related to patient demographics and clinical diagnoses.  HIM / MR  practitioners must work with the hospital’s leaders to constantly seek changes that will co-produce improvement in a continuous cycle while outside regulators for example, the JCI checks on the quality of care of patient care systems and the outcomes they produce.

The measures selected and the analysis of the measurement data must ultimately fit into the hospital’s overall plan for quality measurement and patient safety, when they prove helpful in better understanding or more intensively assessing the areas related to patient demographics and clinical diagnoses that is under study. They also help to formulate strategies for improvement in the area being measured, and subsequent follow-up measures becomes helpful in understanding the effectiveness of the improvement strategy.

References:

  1. Diane, LK 2007, Applying quality management in healthcare : a systems approach, 2nd edn, Health Administration Press, Chicago, Illinois, USA
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn,  Jones and Bartlett Publishers, Sudbury, MA, USA