In continuation to the post JCI Standard MCI.19 Patient Clinical Record, the first standard, its intent and the measurable elements are:
Standard MCI.19
The organization initiates and maintains a clinical record for every patient assessed or treated.
Intent of MCI.19
Every patient assessed or treated in a health care organization as an inpatient, outpatient, or urgent care patient has a clinical record. The record is assigned an identifier unique to the patient, or some other mechanism is used to link the patient with his or her clinical record. A single record and a single identifier enable the organization to easily locate patient clinical records and to document the care of patients over time.
Measurable Elements of MCI.19
- A clinical record is initiated for every patient assessed or treated by the organization.
- Patient clinical records are maintained through the use of an identifier unique to the patient or some other effective method.
Examining the intent and the measureable elements for this standard from above, I think it is important to know answers to the following questions:
Does your hospital initiate and maintain a clinical record for every patient assessed or treated?
A patient or clinical record is defined (Michelle, A.G. & Mary J.B. 2011, pg 70) “as the business record for a patient encounter, contains documentation of all health care services provided to a patient, and is a repository of information that includes demographic data, as well as documentation to support diagnoses, justify treatment, and record treatment results.”1
1Essentials of Health Information” (Michelle, A.G. & Mary J.B. 2011, Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, New York
So since your hospital initiates and maintains a clinical record for every patient assessed or treated, who are these kinds of patient at your hospital?
Hospital patients are usually categorised as ambulatory patients (outpatients), ambulatory surgery patients(e.g., day surgery), emergency care patients, inpatients, newborn patients, observation care patients, and subacute care patients.
Now that you have identified your list of patient types/categories, how do you identify each of these identified groups of patients? State your method and how does it work?
Do you provide a single clinical record or multiple records?
Does your method use an unique identifier? If so, what is this unique identifier?
The Medical Record Number(MRN) is commonly used as this unique identifier.
How do you maintain your patient clinical records?
The above standards do not specify methods for record management, all hospitals must implement systems to effectively manage and control records.
In addition, filing controls are established to ensure accurate filing and timely retrieval of patient records, including:
- Chart tracking system (they could be manual or computerised)
- File guides
- Periodic audit of file system
It is the intent of this standard that using an unique identifier, your hospital can easily locate patient clinical records and to document the care of patients over time. How do you locate your patient clinical records using this unique identifier?
How do you link the patient with his or her clinical record?
A master patient index (MPI), sometimes called a master person index (MPI), links a patient’s medical record number with common identification data elements (e.g., patient’s complete name, date of birth, gender, mother’s maiden name, and social security number).
If your unique identifier is the MRN, then how is your MPI used to link the patient with his or her clinical record?
Your answers to the above questions must be outlined in the HIM/MR departmental policies and procedures. Your answers will provide the JCI surveryor(s) the opportunity to evaluate the compliance to this standard and chances are, he or she will give a full compliance score for this standard, if all is in order and well documented and answers answered well!
