Daily Archives: 01/06/2012

JCI MCI19.1 & MCI19.1.1 – Patient Clinical Record

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The Standard MCI.19.1 states “The clinical record contains sufficient information to identify the patient, to support the diagnosis, to justify the treatment, to document the course and results of treatment, and to promote continuity of care among health care practitioners” , while the Standard (sub-standard) MCI.19.1.1 states that “The clinical record of every patient receiving emergency care includes the time of arrival, the conclusions at
termination of treatment, the patient’s condition at discharge, and follow-up care instructions”.

The clinical record is only complete and can satisfy the above standards if your hospital has implemented a standarised medical record format and content of a patient’s clinical record to help promote the integration and continuity of care among the various practitioners of care to the patient.

Let us now view as below the standards, their respective MEs, and how I suggest (my suggestions in brown) each of these MEs can meet full compliance for these two standards (double-click on each of the following images BELOW for a larger view of each image which will then display in a new tab of the current window of your browser) :

NOTE: With the exception of MCI.19.1 and MCI.19.1, all the other standards in this post refer to other forms of entries in the patient clinical record.


11th International Classification of Diseases

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For the first time, experts in the public health community who work with patient diagnosis and treatment have an opportunity to contribute to the development of the next version of the International Classification of Diseases (ICD), which is WHO’s publication that ensures all members of the health community refer to diseases and health conditions in a consistent way.

WHO is releasing the beta version of what will be ICD-11 on a wiki-type platform that allows stakeholder comments to be added after peer review. The final ICD-11 will be released in 2015.

WHO encourages anyone interested to comment to develop a more comprehensive classification.

Foundation for reliable health data

The ICD is the foundation for the identification of health trends and statistics globally. Receiving input from health experts will greatly improve the representation from current medical practice and create insight from a broader diversity of medicine.

“Literally this is what doctors use to diagnose a patient,” says Tevfik Bedirhan Ustun, coordinator in the Department of Health Statistics and Information Systems. “It is how we define the cause of death when a person dies. In research, it is how we classify health problems based on evidence.”

The ICD is the gold standard for defining and reporting diseases and health conditions. It allows the world to compare and share health information using a common language.

In addition to health providers, the ICD is a key tool used by epidemiologists to study disease patterns, insurers, national health programme managers, data collection specialists, and others who track global health progress and how health resources are spent.

ICD-11 innovations

Using advances in information technology, this ICD revision will allow users to collect data on cause of death, advances in science and medicine, emerging diseases and health conditions, and compare information across the globe with more ease and diversity in the service of public health and clinical reporting.

New features of the 11th version

  • There will be a new chapter on traditional medicine, which constitutes a significant part of health care in many parts of the world.
  • It will be ready to use with electronic health records and applications.
  • It will updated through the development phase to reflect new knowledge as it is added to the classification.
  • It will be produced in multiple languages through the development phase.

How to participate in ICD-11

Public health experts interested in contributing to ICD-11 can review the classification and register to join the consultation now. The final version of ICD-11 will be launched in 2015.

Source: http://www.who.int/features/2012/international_classification_disease/en/index.html