Medical information that require documentation in medical records

Now to go on along the path from my previous post on Standards with requirements that require documentation in a medical record (this link opens in a new tab of your current window), this post is all about aspects of JCI’s standards and requirements that directly affect medical information which requires documentation in medical records.

From all my previous posts on medical information, and a close check on the 4th Edition of Joint Commission International Accreditation Standards For Hospitals, shows that the following medical information requires documentation in a medical record :

1. Initial medical assessments and Initial nursing assessments, both of which are documented in the patient’s record and readily available to those responsible for the patient’s care; these initial assessment(s) results in an initial diagnosis
   1. An initial diagnosis is a very important notation of a doctor’s assessment and his or her learned conclusion to a definite initial diagnosis. So it is undoubtedly a part of medical documentation, and is thus a part of the assessment documentation.
   2. Standard AOP.1.2 has no direct reference to documentation by the doctor and the nurse, obviously the doctor and the nurse will record all their initial assessments in the medical records.
   3. Thus, I have counted this standard as an explicit standard for medical information documentation and as one of the several requirements (more on this after I have concluded posts on surgical information) for what information must be recorded in the medical record by the hospital’s various health care providers.
2. Pain assessments for all inpatients and outpatients who are screened for pain and assessed when pain is present and recorded in a way that facilitates regular reassessment and follow-up
3. All Patient Orders, including medication, diagnostic imaging and clinical laboratory test orders are written in the medical record
4. Care Plans and Team meeting discussions, when the staff responsible for the patient work together to analyse the assessment findings and combine this information into a comprehensive picture of the patient’s condition; from this collaboration, the patient’s needs are identified, the order of their importance is established, and care decisions are made – integration of finding at this point facilitates the coordination of care provision; the results or conclusions of any patient care team meetings or other collaborative discussions are written in the patient’s record
5. A discharge summary which contains follow-up instructions for the patient’s continuing or follow-up care, prepared at discharge by a qualified individual of which a copy is placed in the patient’s medical record

From the list above of medical information that require documentation in a medical record, I have a count of seven (7) standards which explicitly state what is to be documented in a medical record with a total of ten (10) requirements which includes explicit and implicit instances that require documentation in a medical record.

The charts below (a larger view of each chart is displayed in a new tab of your current window, by clicking on each chart) show these 7 standards with the 10 requirements.

I believe, a Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital must be aware and knowledgeable that the quality of his or her medical records, in his or her custody and care is determined by their contents. The medical records must contain all of the medical information as I spoken of above, recorded in them. This condition is regardless of the type of hospital they work at, irrespective if his or her hospital had acquired JCI accreditation status or one that is seeking JCI accreditation status or it is one that is not seeking JCI accreditation status at all.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA