Monthly Archives: April 2013

MSQH – SERVICE STANDARD 7, Organisation and Management for STANDARD 7.1.1

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MSQH-Book-SS7-HMISOrganisation and Management is the first topic among six (6) topics which make up the standards under SERVICE STANDARD 7 for Health Information Management System (HIMS) based on the 4th Edition of the Malaysian Society for Quality in Health (MSQH) Hospital Accreditation Standards effective January 2013, used by the MSQH, which is the sole Malaysian accreditation body with nationally established standards for health care facilities and services since 1997, dedicated to improving the quality of Malaysia’s health care through voluntary accreditation. You can read about the 6 topics from the post MSQH – Introductory Post (this link will open in a new tab of your current window) as well view the hierarchy of these topics (the green boxes) from the graphic below (click on the graphic to view a larger image which will open in a new tab of your current window).

MSQH Service Standard 7

Standard 7.1.1 is the first standard for Service Standard 7 and the only standard under the topic Organisation and Management (OM) which states that “The Health Information Management System (HIMS) Services shall be organised and administered to facilitate the collation, aggregation and analysis of hospital demographic data through an established system which includes safe keeping and retrieval of medical records and documents related to patient care.

Health Information Management (HIM) / Medical Records (MR) practitioners in Malaysia whose hospitals are engaged in hospital accreditation using the 4th Edition of the Malaysian Society for Quality in Health (MSQH) Hospital Accreditation Standards effective January 2013 for the Service Standard 7 HIMS must truely know that his or her hospital needs to fully satisfy fifteen (15) criteria for compliance to the OM topic for this service standard.

The criteria for compliance to the OM topic for this service standard ranges from the organisation management of the HIM / MR Department through processes planning and continued development, data management of information about major clinical services that meets Malaysian statutory requirements, reporting systems for incident reports, the formation and activities of a Medical Records Committee, and ends with the department’s involvement in quality improvement activities.

You can view the whole range of criteria listed from https://docs.google.com/file/d/0B1XnOSMJXDaqR184d1BsbHQxQWs/edit (this link will open in a new tab of your current window) from the Download List Sub-Menu under the Resources Menu.

Now I like to draw your attention to the variation or differentiation between nearly identical entities and other non-identical entities found under MSQH Service Standard 7, Standard 7.1.1 and those found under the  Joint Commission International (JCI) hospital accreditation standards,

HIM / MR practitioners will find a similarity between JCI hospital accreditation found in Standard MCI.9 (which I have not blogged on as yet) with  the MSQH Service Standard 7, Standard 7.1.1 under Criterias 7.1.1.1 to 7.1.1.10 when both of them try to cover aspects of the HIM / MR department’s mission, services provided, resources, access to affordable technology,and support for effective communication among caregivers

HIM / MR practitioners will find another similarity between JCI hospital accreditation found in Standard MCI.19.4 with the MSQH Service Standard 7, Standard 7.1.1 under Criteria 7.1.1.13 which requires regular Medical Records Review (MRR) sessions. However the MSQH Service Standard 7, Standard 7.1.1 under Criteria 7.1.1.13 does not elaborate the review process nor is there any  MMR tool to use unlike that found under JCI.

Unlike hospital accreditation for JCI accreditation status, a specific Root Cause Analysis (RCA) activity is required of HIM / MR practitioners under  the MSQH Service Standard 7, Standard 7.1.1 under Criteria 7.1.1.12 . I hope HIM / MR practitioners will not be wrongly allocated the task of conducting RCA for all incidents that occur in the hospital but rather they will only be confined to RCA for all incidents that occur for HMIS services only. as I understand from Criteria 7.1.1.11, MSQH Service Standard 7, Standard 7.1.1 which stipulates that “The Head of the HIMS Services shall ensure that the staff of HIMS Services complete incident reports which are discussed by the services with learning objectives and forwarded to the Person In Charge (PIC) of the Facility.”

There is no direct reference to “The Medical Records Committee” to be found in JCI. However, HIM / MR practitioners in Malaysia need to be aware that according to the notes found under Criteria 7.1.1.13, MSQH Service Standard 7, Standard 7.1.1 “The Medical Records Committee is a subcommittee of Medical and Dental Advisory Committee (MDAC) who advises the Governing Body on matters pertaining to HIMS.” and not as reporting directly to the Hospital’s Director or other equivalent top management official.

Quality Assurance (QA) Managers and their departments are normally assigned the duties of facilitating quality improvement (QI) activities for the hospital. I can infer that QA managers have a specialised and trained role in QI, and thus are fully qualified to be the facilitator of such QI activities, Nonetheless, Criteria 7.1.1.15, MSQH Service Standard 7, Standard 7.1.1 has assigned this role with the given and added responsibility to HIM / MR practitioners to be the “facilitator for quality improvement activities of the Facility. Areas of involvement may include:

a) compiling patient care data for clinical review/research;

b) supervising data collection and advising on analysis of data collected by personnel of other services.”

Lastly, I find that MSQH Service Standard 7, Standard 7.1.1 does not have set criteria to cover the clause “safe keeping and retrieval of medical records and documents related to patient care.” while on the contrary Standard MCI.12 of the JCI clearly states that “The organization has a policy on the retention time of records, data, and information.”

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. SERVICE STANDARD 7 Health Information Management System 2013, Malaysian Hospital Accreditation Standards, 4th edn, The Malaysian Society for Quality in Health (MSQH), Malaysia

Written Discovery – Part 1, Requests To Produce

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written-discovery-log“The claim is to seek recovery for injuries that the plaintiff believes were caused by the defendant’s failure to meet an established professional duty of care.”, was how I ended the post Written Discovery – Introduction (this link will open in a new tab of your current window), and now to begin this post on what to anticipate and to respond with the information typically requested in all medical-negligence cases and specific information related to the claim of professional or institutional negligence, in both situations consistently and efficiently to written discovery.

Health Information Management (HIM) / Medical Records (MR) practitioners normally assist such requests when they are required to assemble and reproduce all medical information that pertains to the patient, including medical records, letters/reports including films, drawings, diagrams, photographs, and electronic data. I shall write more about this on my next continuing post on written discovery.

I think HIM / MR practitioners need to be aware of other common information with respect to the care at issue in the lawsuit requested from the hospital management which may include from what I have encountered from my experiences:

  1. any quality improvement activities conducted
  2. identification of any hospital policies relevant to the care and treatment at issue
  3. information regarding the identification and employment status of individuals involved in the relevant care and treatment of the patient or who have knowledge of the medical treatment at issue in the lawsuit
  4. any hospital accreditation status e.g Joint International Commission (JCI) or Malaysian Society of Quality in Health (MSQH) accreditation
  5. medical-staff bylaws, policies, and procedures, or other documents that govern the scope of medical-staff practices

During the pendency of the lawsuit, hospitals may be required to seasonably supplement their written-discovery responses with new or additional information identified during the course of discovery. HIM / MR practitioners may also be required to further assist hospital management in providing any new or additional information identified to complete any supplemental discovery requests.

Periodicity Of Reassessments For 13 Situations Found In Medical Records

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Here is a graphic to show a summary of the periodicity of reassessments in 13 situations which can be found in a medical record. Click the image to view a larger image in a new tab of your current window.

Periodicity-Of-Reassessments-For-13-Situations-Found-In-Medical-Records

Reassessment of all patients and results are always entered in their medical records

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Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware of the evidence of reassessment of all patients and results which are always entered in patients’ medical records. The results of these reassessments noted in the patient’s medical record is for the information and use of all those caring for the patient.

Health care practitioners  – predominately doctors and nurses are the ones who routinely conduct reassessment of patients in the following situations:

  1. to determine the patient’s response to treatment and whether the intervention remains appropriate
  2. to plan for continued treatment or discharge
  3. at intervals based on a patient’s condition and when there has been a significant change in his or her condition, plan of care, and individual needs or according to organisation policies and procedures

HIM / MR practitioners also need to be aware that a reassessment is integral to ongoing patient care i.e. it is a continuous process, and it is the key to understanding whether care decisions are appropriate and effective, and are normally carried out at intervals based on the patient’s condition and treatment to determine their response to treatment and to plan for continued treatment or discharge.

However, the periodicity of reassessment depends on the condition as well as a patient’s needs extending to the plan for continued treatment or discharge, or as defined in organisation policies and procedures as in the following situations:

  1. acute care patients are reassessed by the doctor(s) at least daily, including weekends, and when there has been a significant change in the patient’s condition
  2. non-acute patients maybe assessed less than daily and determined by a hospital policy which defines the circumstances in which, and the types of patients or patient populations for which, a doctor identifies the minimum reassessment interval for these patients
  3. nursing staff may be observed to periodically record vital signs as needed based on the patient’s condition in response to a significant change in the patient’s condition
  4. if the patient’s diagnosis has changed and the care needs require revised planning
  5. to determine if medications and other treatments have been successful and the patient can be transferred or discharged
  6. the care of patients undergoing moderate and deep sedation especially the frequency and type of patient-monitoring requirements
  7. the minimum frequency and type of monitoring during anaesthesia which is written into the patient’s anaesthesia record
  8. monitoring of physiological status during anaesthesia administration which is written into the patient’s anaesthesia record
  9. the patient’s physiological status is monitored during surgery and immediately after surgery
  10. the patient’s readiness for discharge based on the patient’s current reassessed health status and need for continuing care or services as determined by the use of relevant criteria or indications from a referral and/or discharge plan begun early in the care process and, when appropriate, which had included the family to ensure patient safety
  11. the collaborative monitoring process on medications by doctors, nurses, and other health care practitioners when they jointly evaluate the medication’s effect on the patient’s symptoms or illness and monitor and report for adverse effects like allergic responses, unanticipated drug/drug interactions, or a change in the patient’s equilibrium raising the risk of falls among others, thus in both cases to allow the dosage or type of medication to be adjusted when needed
  12. when patients are been monitored to their response to a collaborative plan among doctors, nurses, the dietetics service, and, when appropriate, the patient’s family, to provide nutrition therapy after a screening process during an initial assessment to identify those at nutritional risk
  13. dying patients and their families are assessed and reassessed according to their individualised needs by evaluating and managing their symptoms and preventing complications to the extent reasonably possible in the care of these dying patient to optimize his or her comfort and dignity

As I researched for this post, I found that this is the NOT the last in the list of medical record documentation requirements I have found as required by the Joint Commission International (JCI) standards for documentation required in a medical record.

I will still need to discuss on these other medical record documentation requirements:

  1. when a hospital policy identifies adverse effects that are to be recorded in the patient’s record and those that must be reported to the hospital
  2. when the patient’s response to nutrition therapy is recorded in his or her record
  3. when assessments and reassessments need to be individualised to meet patients’ and families’ needs when patients are at the end of life, and assessment findings are documented in the patient’s medical record

Nonetheless, any hospital’s medical record documentation, irrespective if the hospital had undergone the journey to JCI accreditation or is planning to do so, all of which will contain reassessment findings recorded in them, including that related to needs when patients are at the end of life.

So if you are practising at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then your hospital will need to fully comply with the JCI Standard AOP.2 which states that “All patients are reassessed at intervals based on their condition and treatment to determine their response to treatment and to plan for continued treatment or discharge.” Documentation of reassessment of patients in their medical records also satisfies the JCI Standard MCI.19.1, Measurement Element 5 requirement which states that “Patient clinical records contain adequate information to document the course and results of treatment.”.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

“Seems nine codes for a turkey assault is a bit silly.”

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A turkey is  a large bird, one species commonly known as the wild turkey is native to the North American continent, while the domestic turkey is a descendant of this species.

I have never encountered coding for being assaulted by a turkey using ICD 10 in Malaysia. This morning I was amused to find out from a blog that a US legislator, Rep. Ted Poe (R-Texas) was fully aware of the array of ICD 10 codes available for the following conditions, especially the codes available for being assaulted by a turkey:

  • Nine codes for being assaulted by a turkey, one code for being assaulted by a turkey for the first time, one code for being assaulted by the turkey a second time etc.
  • Five codes for being hit in the face by a basketball; and
  • Three codes for being injured by walking into a lamppost.

Poe highlighted these codes in his recent speech when he had criticised the forthcoming ICD 10 medical coding mandate in the US by October 2014. He believes that the level of such detail required for ICD 10 coding “a bit silly”, and would pose challenges for US health care providers.

A check using ICD 10 does not provide codes for the above external cause of injury(s), with such specificity.

But such specificity is provided for in ICD-10-CM.

For example, encounters with a turkey (not necessarily the same turkey) is classified to nine codes, one for “contact with turkey”, one code for “struck by turkey” which has three other codes under this code that describe this diagnosis in greater detail, and one code for “pecked by turkey” which has three other codes under this code that describe this diagnosis in greater detail.

But this is not the same as I think as Poe comprehended based upon his remarks, meaning nine codes assigned for nine encounters of one patient, each of these nine codes assigned for assault by turkey multiple times by one same turkey or different turkeys!

I think it would be absolutely absurd if a patient were to present at a hospital with nine encounters, one after another encounter as a result of assault by a turkey or turkeys, right?

If a patient was struck by a turkey in Malaysia, how would I code to ICD 10. Malaysia does not use ICD-10-CM.

One has to examine Volume 3 of ICD 10 first, to make “clever” (not implying anything here, perhaps “trained” is a better choice of word) decisions in order to assign a near accurate code using ICD 10, unlike my pal in the US using ICD-10-CM. I say “clever” because, you need to find what term(s) define the external cause of injury, which means narrowing down the choice of adjectives defining the lead term(s) for the external cause of injury to search for in Volume 3. I think a good command of the English language is absolutely necessary.

If the doctor had written “struck by turkey” then it would be easy to turn to Section II, Volume 3 and search for the lead term “struck”. Otherwise it is like finding a needle in a hay-stack, searching for the right lead term to look under.

While medical records documentation is not near the desirable quality to expect in most instances, experience in ICD coding will ease this burden when one had encountered such coding problems. However, Health Information Management (HIM) / Medical Records (MR) practitioners still need to examine the entire medical record to find clues to assign an appropriate ICD-10 code in such instances, or simply get back to the attending doctor for help and advice.

So an amateur coder would look under “contact”,  and/or “hit” (which asks to “see Struck by”), and/or “exposure”.  If you look under (i) “contact”, you will find “contact with animal NEC” and the code W64.-., (ii) “hit”, you will find that you are redirected to go to “see Struck by”, and if you look under (iii) “exposure”, there is no find.

So you just go to “struck” for (ii) above or from “hit” to “struck” and your find “animal (not ridden) NEC and the code W55.-

Since birds are also animals like mammals, reptiles, fish and insects, then the turkey is an animal.

So the code is either W55- OR W64.-.

Checking Volume 1, W55.- states the code as “Bitten or struck by other mammals” while W64.- states the code as “exposure to other and unspecified animate mechanical forces”.

A turkey is a bird and not a mammal, so W55.- is not appropriate already, and I am left with W64.- only.

A turkey which strikes a patient must have been agitated, be it either a wild or a domesticated one ( I can only visualise a domesticated turkey in Malaysia, like those bread for poultry at Jitra, Kedah, Malaysia or a patient raring turkeys at his or her home).

So if the turkey strikes at the patient, then it runs towards the patient with mechanical forces using its legs. Thus, its movement is animated, and mechanical, and I would choose to assign the ICD 10 code W64.-, in this case of a patient exposed to a turkey attack or assault which runs towards the patient with animated motion using the mechanical forces of its legs.

From this example it is clear that ICD 10 is not as specific as ICD-10-CM.  That is why ICD 11 is on the way which I think will be more granular that ICD 10.

References:

  1. Badriyah Turkey Farm, viewed 15 April 2013, < http://badriyahturkeyfarm.blogspot.com/ >
  2. ICD10Data.com, viewed  15 April 2013, < http://www.icd10data.com/Search.aspx?search=turkey&codebook=AllCodes >
  3. Kasperowicz, P, Floor Action Blog, The Hill, viewed 15 April 2013, < http://thehill.com/blogs/floor-action/house/292961-lawmaker-rejects-medical-code-mandate-mocks-nine-codes-for-being-assaulted-by-a-turkey >