31/08/2012

Now I have completed relevant posts on surgical information that belong to the contents of a typical medical record for a patient who had undergone surgery, I like to summarise the Joint Commission International (JCI) standards and requirements that directly affect surgical information which requires documentation in medical records.

At this juncture, I like to reiterate that I am not advocating JCI’s program for hospital accreditation. I have used their standards as a benchmark to make medical records documentation to a better quality and as evidence of proper care.

I have also run up each post with a background to a specific surgical information in the medical record, so that Health Information Management (HIM) / Medical Records (MR) practitioners are not just managing medical records literally and not understanding and knowing the background of pieces of scientific information which accumulates inside the medical records.

In my opinion, knowing the nature and structure of surgical information in a medical record make a better HIM/MR practitioner, who is able to stand up for and argue for the quality of medical and surgical information in medical records.

Someone has to fight for the quality of medical records, and who is less important and relevant than HIM/MR practitioners who are the rightful custodians of medical records. I think it is not HIM/MR management practice is not only about medical records assembly, filing, coding, preparing statistical reports and medico-legal processing, etc., but accruing knowledge on HIM/MR management with regards to “WHAT is this thing we are managing”, “WHY are we keeping this?”, and ”HOW can we contribute to the quality of documentation?”.

From 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 records 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.

For surgical information that require documentation in a medical record, I have 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.

I have tabulated all the 12 requirements in some charts. But before displaying the charts on the 12 requirements, allow me to summarise the perioperative period for a patient scheduled for surgery in the pictorial below. I think this chart below is relevant to understanding the 12 requirements (a larger view of this chart is displayed in a new tab of your current browser window by clicking on this chart).

And now, the charts below (a larger view of each chart is displayed in a new tab of your current window, by clicking on each chart) show the 12 requirements for surgical information.

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I believe, a HIM) / MR practitioner working in a hospital must be knowledgeable enough of the surgical information contents in the medical records in his or her custody and to contribute greatly to their quality. The medical records must contain all of the surgical 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.

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

Another surgical information that goes into the medical record is the postsurgical care plan to surgical patients. A postsurgical care plan is important for discharge planning and future planning are based on medical and nursing care plans after surgery. The Joint Commission International (JCI) Standard ASC.7.4 also emphasises the importance for such a plan through its statement which reads, “Patient care after surgery is planned and documented.”

As each surgical patient’s postsurgical medical and nursing care needs usually differ, immediate postsurgical care is planned and includes medical, nursing, and others as indicated by the patient’s defined needs. The postsurgical care plan which can begin before surgery based on the patient’s assessed needs and condition, includes the level of care, care setting, follow-up monitoring or treatment, and need for medication.

The postoperative phase (which is each surgical patient’s postsurgical care period) continues until the patient is released from the surgeon’s care. When the client is discharged from the postanesthesia care unit (PACU), the surgeon will later decide the next level of care and the care setting for the patient. The surgeon documents in the postsurgical plan whether the patient goes either directly to an inpatient hospital bed or to the outpatient ambulatory unit for observation or to discharge the patient to the patient’s home.

The postsurgical care plan will also contain information on follow-up monitoring of the postoperative patient’s return to normal (baseline) respiratory function and cardiopulmonary function and the patient is free from signs of a wound infection within 72 hours after surgery.

Postoperative discomforts like pain – which is usually most severe immediately after the patient’s recovery from anaesthesia, postoperative nausea, urinary retention, postoperative constipation, postoperative flatus all require treatment and need medication. The treatment(s) and medications form part of the postsurgical care plan documentation.

A Health Information Management (HIM) / Medical Records (MR) practitioner will find among the contents of a medical record for a patient who had undergone surgery, a postsurgical plan(s) documented in the patient’s medical record by the responsible surgeon or verified by the responsible surgeon by co-signature on the documented plan entered by the surgeon’s delegate. The nursing postsurgical plan of care and when indicated by the patient’s needs, the postsurgical plan of care provided by others are also documented in the patient’s medical record. These are often documented in the progress notes. However, nursing care plans are not usually filed in the permanent patient record. The date and time for each of the plans of care documented in the patient’s medical record are evidence to verify that each planned care was provided and documentation was done within 24 hours of the surgery.

With this post, I believe I have completed posts on anaesthesia care and surgical care which have explicit reference to surgical documentation in a medical record for a patient who undergoes surgery.

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