I have based my previous posts on medical record documentation on the Joint Commission International (JCI) Standards found in the Joint Commission International Accreditation Standards For Hospitals, 4th Edition and The Joint Commission International Accreditation Hospital Survey Process Guide, 3rd Edition.
To round-up writing about all matters related to medical record documentation based on JCI’s Standards, I have recently discovered in the course of my study of the above mentioned manual/guide, that I need to write about three assessment activities to include under medical record documentation, before I can categorically state I have completed all of the required contents of a medical record to fully satisfy all JCI’s Standards related to medical record documentation and the process of a closed Medical Records Review.
To this effect, the remaining 3 posts on medical record documentation will cover :
- the information gathered at the initial medical and/or nursing assessment when patients are screened for nutritional status and functional needs and are referred for further assessment and treatment when necessary, including a fall-risk assessment;
- the need for discharge planning at the initial assessment for those patients for whom discharge planning is critical due to age, lack of mobility, continuing medical and nursing needs, or assistance with activities of daily living, among others; and
- reassessment conducted by a doctor in the ongoing patient care and when results are noted in the patient’s medical record for the information and use of all those caring for the patient.
For Health Information Management (HIM) / Medical Records (MR) practitioners working at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, you will need to take note that all of the 3 assessment activities listed above are included in the closed Medical Records Review.Tool.
References:
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Joint Commission International 2010, The Joint Commission International Accreditation Hospital Survey Process Guide, 3rd edn, JCI, USA
