JCI Standard MCI.19.4 – Patient Clinical Record

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.