Daily Archives: 25/07/2012

Plan Of Care

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Problems are identified from the initial medical and nursing assessments for each patient, and a plan of care (POC) is implemented soon after by the responsible physician, nurse, and other health professionals with the involvement of the patient and family to address these problems using the data from the initial assessments.

Image credit : todaysseniorsnetwork.com

The POC is a written guide that organises data about a patient’s care into a formal statement that will be used to help the patient achieve optimal health. Therefore, a carefully formulated written plan of care is developed within 24 hours of admission as an inpatient in order to provide quality patient care by prioritising problems and addressing short- and long-term needs of the patient by prioritising treatments, setting realistic goals and developing expected outcomes (outcome identification), planning medical and nursing interventions (with collaboration and consultation between care providers as needed) to meet the patient’s needs, and finally documenting the care plan.

Systematic monitoring and observation performed by the patient’s health care practitioners related to specific problems during ongoing assessments (reassessment) allow to determine the patient’s response to medical and nursing interventions and to identify any emerging problems so as to update the plan as appropriate or to confirm the validity of the data obtained during the initial assessments, thus allowing in compiling a comprehensive database of the patient’s health to achieve the desired outcomes.

Reassessment detect the patient’s changing needs as the result of clinical improvement or new information from a routine reassessment (for example, abnormal laboratory or radiography results), or they may be evident from a sudden change in the patient’s condition (for example, loss of consciousness). The plan for the patient’s care also changes.

The Joint Commission International (JCI) Standard COP.2.1 requires the documentation of a single, integrated care plan that identifies measurable progress (goals) expected by each discipline as opposed to the entry of a separate care plan by each practitioner. This individualised plan of care related to his or her identified needs must be evident for each patient in the patient’s medical record.

During the accreditation survey, the reviewer looks for evidence of an organised and systematic method of monitoring and evaluating patient care that is reflected through changes in the documentation of the medical record as notes to the initial plan or as revised or new care goals, or in a new plan.

The Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital with JCI accreditation status or one that is seeking accreditation status must ensure that all medical records are complete with a  POC.

Medical records will be used to proof evidence of POC for each patient to fully meet the seven (7) requirements for this standard which ensures compliance with JCI’s plan of care requirements as follows :

  1. The care for each patient is planned by the responsible physician, nurse, and other health professionals within 24 hours of admission as an inpatient
  2. The planned care is individualised and based on the patient’s initial assessment data
  3. The planned care is documented in the record in the form of measurable progress (goals)
  4. The anticipated progress (goals) is updated or revised, as appropriate, based on the reassessment of the patient by the interdisciplinary health care practitioners
  5. The care planned for each patient is reviewed and verified by the responsible physician with a notation in the progress notes
  6. The planned care was provided
  7. The care provided for each patient is written in the patient’s record by the health professional providing the care

Since Standard COP.2.1 clearly states the POC provided to each patient is planned and written in the patient’s record by the health professionals providing the care, justifies this standard to be included as medical information.

References :
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

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

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Standards with requirements that require documentation in a medical record

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The rush for Joint Commission International (JCI) accreditation and certification has spread across Asia – from Turkey and Jordan to China and Singapore, and of course to Malaysia too.

In the wake of this rush by many hospitals which are on their way to acquire what is known as a “Gold seal of Quality”, an international accreditation award given to healthcare establishments internationally if they meet or exceed JCI standards by JCI based in the United States, I think it is imperative that Health Information Management (HIM) / Medical Records (MR) practitioners working in such hospitals must examine how JCI accreditation and certification affects them and what they must do to thrive under it.

In this post and in subsequent posts, read about the aspects of JCI accreditation and certification that directly affect medical information and surgical information that require documentation in medical records, and to learn about the role of care providers play for what portions of both medical and surgical information that must be recorded in the medical record (what they say) from what they do to improve quality of patient care and reduce costs in this quality system of accreditation and certification.

Allow me to lead you along the path of another new post after this one, to aspects of  this quality system of accreditation and certification from JCI that directly affect medical information that require documentation in medical records.

But before that, some rules to identify the standards and the requirements found in the Joint Commission International Accreditation Standards For Hospitals 4th Edition relevant to medical information and surgical information, that require documentation in a medical record which form the greater part of what is called “the contents of a medical record”.

Familiarity with the Joint Commission International Accreditation Standards For Hospitals 4th Edition indicates that JCI has standards which explicitly state what is to be documented in a medical record and also has standards which implicitly hints what is to be documented in a medical record.

Standards which explicitly state in the standard statement and / or  in a corresponding Measurable Elements (ME) of each standard what is to be documented in a medical record contain statement(s) and /or phrases like :

  • Standard AOP.1.3 statement which states “The patient’s medical and nursing needs are identified from the initial assessments and recorded in the clinical record.”
  • Standard ASC.5.2 statement which states “The anesthesia used and anesthetic technique are written in the patient record.”
  • “documented in the patient’s clinical record”
  • “entered into the patient’s clinical record”
  • “recorded in the patient’s record”
  • “written in the patient’s record”

For example, Standard AOP.1.3 states “The patient’s medical and nursing needs are identified from the initial assessments and recorded in the clinical record.”, and has two MEs that explicitly state what is to be documented in a medical record, namely ME3 and ME 4 which state “The identified medical needs of the patient are documented in the patient’s clinical record.” and “The identified nursing needs of the patient are documented in the patient’s clinical record.”, respectively.

Standards which implicitly hint to what is to be documented in a medical record have words or phrases or complete statements which hint of documentation of what is to be included in a medical record like :

  • “The clinical records of inpatients contain a copy of the discharge summary.”, which is the Standard ACC.3.2 statement
  • “The initial assessment(s) results in an initial diagnosis” which is the ME 4 for the Standard AOP.1; an initial diagnosis is obviously a medical information by a doctor
  • “Patient records contain a list of current medications taken prior to admission, and this information is made available to the pharmacy and the patient’s health care practitioners.” which is the ME 5 for the Standard MMU.4

For example, the Standard ACC.3.2 states “The clinical records of inpatients contain a copy of the discharge summary.” and its corresponding ME 3 states “A copy of the discharge summary is placed in the patient record.”

Standards which explicitly state what is to be documented in a medical record and standards which implicitly hint what is to be documented in a medical record, make up the “requirements”  to form the greater part of the contents of a medical record. To make it clearer, I mean to say “requirements” refers to what goes into a medical record.

Image credit : http://www.ppt-learning.com/

I guess I have made the rules clear for an understanding of my next post on medical information that warrants documentation in a medical record.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA