My purpose of writing this post is to highlight that the Medical Records Review Tool (MMRT) form contains a provision to check for compliance to “Medical assessment in 24 hours. Updates if less than 30 days old. Nursing assessment in 24 hours” documentation in a medical record during a Medical Records Review (MMR) session.
Members of a MMR session must be able to connect this provision found in the MMRT form to the Joint Commission International (JCI) Standard AOP.1.4.1 which requires that “The initial medical and nursing assessments are completed within the first 24 hours after the patient’s admission as an inpatient or earlier as indicated by the patient’s condition or hospital policy.”
However, most members of the MMR session are usually unaware of this requirement, and it is the duty of the team leader to explain this standard which requires that to begin correct treatment for a patient as quickly as possible, the initial assessments must be completed as rapidly as possible.
Members of the MMR session must be breifed that the hospital determines the time frame for completing assessments, in particular the medical and nursing assessments depending on a variety of factors including:
- the types of patients cared for by the hospital,
- the complexity and duration of their care, and
- the dynamics of conditions surrounding their care.
Nonetheless, it is important for the team leader to stress that all initial medical and nursing assessments must be completed within 24 hours of admission to the hospital and available for use by all those caring for the patient.
The team leader must also indentify situations when the patient’s condition indicates, that the initial medical and/or nursing assessment are conducted and available earlier and supported by a hospital policy which define that certain other patient groups are assessed sooner than 24 hours.
Such certain other patient groups who are assessed sooner than 24 hours will include:
- emergency patients
- patients seen in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient
The above certain other patient groups will be assessed within different time frames as follows :
- emergency patients are assessed immediately
- when the initial medical assessment is conducted in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient, it must be no older than 30 days but (i) if the medical assessment is more than 30 days old, then the medical history must be updated and the physical examination repeated and (ii) if the medical assessment is less than 30 days old but if at the time of admission there are significant changes in the patient’s condition since the assessment was first done, then they are noted in the patient’s medical record at the time of admission to inpatient status.
The team leader may include to explain the rationale why the above 30 days time frame applies when the assessment is completed in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient. Such explanation may include (JCI, 2010 p. 80) “the critical nature of the findings, the complexity of the patient, and the planned care and treatment (for example, the review confirms the clarity of the diagnosis and any planned procedures or treatments; the presence of radiographs needed in surgery; any change[s] in the patient’s condition, such as control of blood sugar; and identifies any critical lab tests that may need repeating)”, findings by any qualified individual (medical, nursing, and other individuals and services responsible for patient care) who usually will update and/or re-examine this patient group.
Reader can relate this post to the previous post Assessments within 24 hours (this link will open in a new tab of your current browser window) on the JCI Standard AOP.1.5 which states that “Assessment findings are documented in the patient’s record and readily available to those responsible for the patient’s care.”
References:
Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
