Cartoon credit: theragblog.blogspot.com/
Health Information Management (HIM) / Medical Records (MR) practitioners maybe unaware of information documented in the patient’s medical record when inpatients and outpatients seeking care and/or diagnostic services patients, undergo long waiting periods for diagnostic and/or treatment services or when obtaining the planned care may require placement on a waiting list.
The issue of waiting periods for healthcare may be described from the study by Singh et al. (2010) as patient-related i.e delays referring to the time period from the onset of symptoms to the patient’s seeking of medical advice or health system-related. Singh et al. (2010) define health system delays to the time period from the first contact of the patient with the health care system to definitive treatment, which may also include delays in patient access to first contact. Singh et al (2010) further categorised health system delays into diagnostic delays defined as time from the patient’s first contact with the health care system to diagnosis and treatment delays as time from diagnosis to definitive treatment.
HIM / MR practitioners practising at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, must be aware that the JCI Standard ACC.1.1.3 which states that “The organization considers the clinical needs of patients when there are waiting periods or delays for diagnostic and/or treatment services.” which requires the aforesaid reasons and alternatives on waiting periods to be duly documented in the patient’s medical record and this requirement applies to:
- inpatient and outpatient care and/or diagnostic services
- does not include minor waits in providing outpatient care or inpatient care, such as when a doctor is behind schedule
- does not apply for oncology cases or transplant cases
To this end, HIM / MR practitioners must:
- be able to locate information recorded in the patient’s medical record that will contain the associated reasons for the delay or wait and available alternatives consistent with their clinical needs;
- must be aware that the JCI Standard ACC.1.1.3 is included in the Medical Records Review Tool; and
- include this requirement in HIM / MR written policies and/or procedures to support consistent practice.
References:
- Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
- Singh, H, Coster, DC, Shu, E, Fradette, K, Latosinksy, S, Pitz, M, Cheang, M & Turner, D 2010, Wait times from presentation to treatment for colorectal cancer: A population-based study, Canadian Journal of Gastroenterology, vol. 24, no. 1, pp. 33–39, viewed 2 July 2013, < http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2830632/#__ffn_sectitle>
