To round-up and complete the subject on the necessary and relevant documentation in a medical record as can be found in the 4th Edition of Joint Commission International (JCI) Accreditation Standards For Hospitals, in this post of two posts, I shall take bring you the final count down of all such necessary and relevant documentation in a medical record.
Health Information Management (HIM) / Medical Records (MR) practitioners please take note (from my knowledge about JCI quality standards) that there are 28 standards with 37 requirements for what information must be recorded in the medical record by the hospital’s various health care providers. Here I mean that there are 37 types of entries that must be recorded (which includes entries related to the 28 standards) in a medical record.
In the post Medical information that require documentation in medical records (this link will redirect you to a new tab of your current browser window), I had presented all the necessary requirements about of medical information that require documentation in a medical record which explicitly stated what is to be documented in a medical record and also standards which implicitly indicated medical information that require documentation in a medical record. I had 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.
For surgical information that require documentation in a medical record, I had made a count of twelve (12) standards* – or also as one can say “requirements”, which explicitly state what is to be documented in a medical record. There are no standards that indicate implicitly any necessity for surgical information to be documented in a medical record. This bit of information I carried in the post Surgical information that require documentation in medical records (this link will redirect you to a new tab of your current browser window).
Thus from the above, I have a total count of twenty-two (22) standards that make up medical and surgical documentaion in a medical record.
Now, from subsequent posts I had written about other standards that make up for what information that must be recorded in the medical record by the hospital’s various health care providers, I have a count of nine (9) such posts. Here are the relevant links to the posts :
PFE.2 : Medical records should contain the patient’s educational needs assessment documentation
ACC.4.4 : 5 transfer process entries that must be entered in a medical record
PFR.6.2 When others can grant consent
PFR.6.3 : General consent is not informed consent
PFR.8 : Informed consent in clinical research, clinical investigation, and clinical trials
ASC.5.1 : Risks, benefits, and alternatives of anaesthesia
MCI.19.3 : JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record – (i) the author can be identified for each patient clinical record entry, (ii) the date of each patient clinical record entry can be identified, and (iii) when required by the hospital, the time of an entry can be identified.
MCI.19.1.1 : JCI MCI19.1 & MCI19.1.1 – Patient Clinical Record – the clinical records of emergency patients include (i) arrival time, (ii) conclusions at the termination of treatment, (iii) the patient’s condition at discharge, and (iv) any follow-up care instructions.
In the coming weeks, I shall be posing on six (6) more standards that require for what remaining information that must be recorded in the medical record by the hospital’s various health care providers.
Once again, I must reiterate that I believe a HIM / 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.
*I have updated the post "Surgical information that require documentation in medical records" due to a technical error
References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
