Process to integrate and to coordinate the care provided to each patient

The previous post Collaboration, and the holistic care of the patient (this link will open in a new tab of your current window), discussed collaboration between members of an interdisciplinary health care team in a hospital comprising of medical, nursing, and other individuals and services responsible for patient care when they use an interdisciplinary approach to analyse and to integrate patient assessments through which they identify the most urgent or important care needs for the patient.

Any results or conclusions from collaborative patient care team meetings or similar patient discussions reflecting this integration and coordination of care are written into the patient’s medical record showing each practitioner’s own observations and treatments.

If there is documentation in the medical record of patients as evidence of a process to integrate and to coordinate the care provided to each patient in the hospital, then this evidence meets the  Joint Commission International (JCI) requirement for the Standard COP.2 which states “There is a process to integrate and to coordinate the care provided to each patient”.

Integrating and coordinating care planning and care delivery among settings, departments, and services meets the JCI Standard COP.2 and the requirements ME1 and ME2. Documenting the results or conclusions of any patient care team meetings or other collaborative discussions in the patient’s medical record in turn meets the JCI Standard COP.2 requirement ME 3.

A Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital with JCI accreditation status or one that is seeking accreditation status, must know how the patient’s medical record facilitates and reflects the integration and coordination of care when each practitioner records observations and treatments in the patient’s medical record. Also, when any results or conclusions from collaborative patient care team meetings or similar patient discussions are written in the patient’s medical record.

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