I continue my tirade(certainly not trading an angry or violent speech here, but what I actually mean is trying to strongly inform you that more than working behind the confines of the HIM/MR Department walls you work in, there exists overseeing matters that we need to pay attention at the same time) on STANDARDS for example, JCI’s standards for Management of Communications and Information (MCI) chapter.
In my earlier post on JCI Accreditation Standards for Hospitals – Introductory Post, I started off with mention of the MCI standards chapter, and subsequently dwelled on the its first standard in the JCI Standard MCI.1 post.
Here now before I discuss other standards of MCI, I like to direct you to one subject matter dearest to all of you as HIM/Medical Records professionals.
The matter is about the Patient Clinical Record, be it paper based or EMR. I think the concepts hold true for both media.
Let us look at the standard pertaining to a Patient Clinical Record, which is MCI.19
The structure of this standard is made of one main standard(MCI.19), four sub-standards(MCI.19.1, MCI.19.2, MCI.19.3 and MCI.19.4 ) and one sub-sub-standard(MCI.19.1.1), all pertaining of course to a Patient Clinical Record – this categorisation is entirely mine, just to makes things easier to understand I think (at least for me) and clearer.
The standards as quoted from JCI’s manual, page 231 goes like this:
- MCI.19 The organization initiates and maintains a clinical record for every patient assessed or treated.
- MCI.19.1 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.
- MCI.19.1.1 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.
- MCI.19.2 Organization policy identifies those authorized to make entries in the patient clinical record and determines the record’s content and format.
- MCI.19.3 Every patient clinical record entry identifies its author and when the entry was made inthe record.
- MCI.19.4 As part of its performance improvement activities, the organization regularly assesses patient clinical record content and the completeness of patient clinical records.
Knowing these standards will help us know if our records keeping ways do keep up with a benchmark, in this instance that set by JCI. In this way, I believe we can then excel in records keeping and maintain high standards of professionalism in our work.
Pals, I am aware I am taking you into a discourse deeper and deeper related to a techinical discussion.
I wish and I shall try to relate to these standards with a social theme, since I did profess that this website-blog would be largely a social medium, but sadly it does not seem so as I do not see any interaction of ex-colleagues nor persons actively engaged still in HIM/Medical Records. My intention is to get people talking here, so this website-blog behaves like a social media thing where people connect and exchange views and as examples, to know where each other are located and working at and for whom, how they are doing in their chosen profession etc.
Nevertheless, I shall discuss more on MCI.19 in a future post.
