Never miss out an adverse event in the medical record!

JCI Standard MMU.7 imageA hospital will normally have a policy that identifies all adverse effects that are to be documented in a medical record and those that must be reported to the hospital’s authorities within a specified time frame. An adverse event is defined as “an unanticipated, undesirable, or potentially dangerous adverse effect occurrence” in a hospital (JCI ASH p.246).

Patients are reassessed to determine their response to treatment on medications since they may suffer adverse effects like allergic responses, unanticipated drug/drug interactions, or a change in their equilibrium raising their risk of falls. Therefore, patients are constantly monitored for medication effects including adverse effects through the collaborative efforts between patients themselves, their doctors, nurses, and other health care practitioners (i) to evaluate the medication’s effect on the patient’s symptoms or illness, as well as blood count, renal function, liver function, and other monitoring with select medications, (ii) to observe the patient for adverse effects, and (iii) to record in the patient’s medical record any adverse effect(s).

This monitoring process is normally a proactive approach to risk management of a hospital with a formalised program of risk management to investigate and to reduce identified, unanticipated adverse events and other safety risks to patients and staff.

The accreditation process is well known as an effective quality evaluation and management tool designed to create a culture of safety and quality within a hospital. One of the benefits of accreditation is it strives to continually improve patient care processes and results.

If your hospital is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then the basics of data gathering and preparation includes selection of measures, data collection and aggregation, data analysis and interpretation, dissemination/transmission of findings, taking action, monitoring performance/improvement are all integral to improving safety and quality of care at your hospital. Medication management data collection issues are either addressed during the System Tracer (Data Use) as a shorter survey or during the full System Tracer – Medication Management survey.

I like to draw your attention when individuals like you as a Health Information Management (HIM) / Medical Records (MR) practitioner may be roped in as part of the hospital’s group of participants during the System Tracer (Data Use) survey since you could be considered as “Individuals who are knowledgeable about the information systems available for data collection, analysis, and reporting” (JCI HSPG p.74) or excluded if a shorter survey just for medication management data collection issues are to addressed.

Do take note too that if you are at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, the Medical Record Review Tool (MMRT).will now check for compliance of the JCI Standard MMU.7 which states that “Medication effects on patients are monitored.”, which this post is all about.

Readers, this post on the JCI Standard MMU.7 and all the rest of the standards I have posted using the JCI Hospital Accreditation Standards 4th Edition, concludes all of the necessary and mandatory documentation standards that must be included in a complete medical record. For hospitals not yet on the JCI journey, I think applying all the standards that are mandatory documentation standards using the JCI Hospital Accreditation Standards 4th Edition augurs for high quality medical records documentation standards at any hospital.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals (ASH), 4th edn, JCI, USA
  2. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA

JCI Standard MCI.4 – accuracy and timeliness of information in the hospital through effective communication

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My intention in bringing this post to a Health Information Management (HIM) / Medical Records (MR) practitioners reader specifically and to all other readers in general, is to understand the dynamics of communication and your role in managing patient-specific information in a hospital setting when the leaders of the hospital agree to an essential condition  whereby effective communication must prevail among and between professional groups; structural units, such as departments; between professional and non-professional groups; between health professionals and management; between health professionals and families; and with outside organisations.

In making this agreement for effective communication throughout the hospital setting, I agree the stipulations that this issue is primarily a leadership function of the hospital’s leaders. This agreement is stipulated in the Joint Commission International (JCI) Standard MCI.4 which states that “Communication is effective throughout the organization”, especially so if you are practising in a hospital accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

The reader as a leader of a structural unit setting and relevant service needs to be aware of the following conditions in this agreement for effective communication:

  1. for patient care to appear seamless, processes must be in place for communicating relevant information in an accurate and timely manner throughout one’s structural unit, such as the HIM / MR department and between other structural units in the hospital; this is to ensure that the processes are designed and implemented to support continuity and coordination of care as patients move through the hospital from admission to discharge or transfer, several departments and services and many different health care practitioners may be involved in providing care; for example from emergency services to inpatient admission
  2. the hospital defines the patient-specific information, example patient’s weight and other physiological information available from the medical record, required for an effective review process and is facilitated by a record (profile) i.e via medication administration records (MAR) or medication list, also to be found within a medical record for all medication administered to a patient except emergency medications and those administered as part of a procedure; the medical record folder is updated after a review of a patient receiving medications, example the folder is tagged with an alert sticker for allergies or sensitivity; this review also facilitates the medication reconciliation process across the continuum of care and the process continues upon discharge and transfer of the patient, and the complete list of patient medications is shared with the next provider of patient care
  3. effective communication occurs in the hospital among the hospital’s programs ranging from the emergency services, inpatient admission, diagnostic services and treatment services, surgical and non-surgical treatment services and outpatient care programs for seamless care
  4. since patients frequently require follow-up care to meet on-going health needs or to achieve their health goals, there is a plan by the hospital’s leaders with the leaders of other health care organisations in its community for effective communication to occur between the leaders of these other health care organisations in its community during referrals; the plan establishes contact with known resources i.e. the patient’s home community and identified specific individuals and agencies that are most associated with the hospital’s services and patient population in order that they help support continuing health promotion and disease prevention education
  5. there are policies and procedures developed to support and to promote patient and family participation in care processes to ensure that continuity and coordination are evident to the patient; effective communication thus occurs with patients and families in these circumstances:
    1. patients and families are involved in care decisions by effective communication thus occurs with patients and families when (i) they understand how and when they will be told of planned care and treatment(s), (ii) understand their right to participate in care decisions to the extent they wish and learn about how to participate in care decisions
    2. inpatients and outpatients who leave against medical advice when patients, or those making decisions on their behalf, may decide not to proceed with the planned care or treatment or to continue care or treatment after it has been initiated guided by a process for the management and follow-up of such cases
    3. effective communication thus occurs with patients and families when those who provide education encourage patients and their families to ask questions and to speak up as active participants
    4. effective communication occurs with patients and families when indicated, planning for referral and/or discharge begins early in the care process ie. soon after admission as inpatients and, when appropriate, includes the family
    5. effective communication occurs with patients and families when patients are reassessed to plan for continued treatment or discharge
    6. effective communication occurs with patients and families such that symptoms and complications are prevented to the extent reasonably possible during the care of the dying patient
  6. and finally. the reader as a leader must not only set the parameters of effective communication but also serve as role models with effective communication of the hospital’s mission and appropriate policies, plans, and goals to all staff.

I acknowledge the role of effective communication and its pervasiveness in creating, gathering and sharing health information in meeting challenges and improving health care outcomes. In this post, I think I have achieved to address some pertinent issues relevant to effective communication when implementing the requirements of the JCI Standard MCI.4 specifically and also delving into the issues of effective communication in general.

References:

  1. Dale, EB & Daena, JG (eds.) 2009, Communicating to manage health and illness, Routledge, London, UK
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
  4. Sheila, P & Sandra, H (eds.) 2007, Health communication Theory and practice, Open University Press, McGraw-Hill Education, England, UK

Documentation of medication administration in medical records

Joint Commission International defines medication (JCI 2010) as ‘any prescription medications; sample medications; herbal remedies; vitamins; nutriceuticals; over-the-counter drugs; vaccines; or diagnostic and contrast agents used on or administered to persons to diagnose, to treat, or to prevent disease or other abnormal conditions; radioactive medications; respiratory therapy treatments; parenteral nutrition; blood derivatives; and intravenous solutions (plain, with electrolytes and/or drugs.’

Preparation for medication administration in a hospital begins with the order for medication, in most circumstances written by a doctor. A record of orders for medication (medications prescribed or ordered), the dosage and times the medication and other treatments was administered is kept in the medical chart of each patient.

Frequency of administration is most often ordered on a repeating schedule (ie, every 8 hours). At times the order may be written as a STAT (give right away) order, a one-time order (give just once) or a prn (medications administered “as needed”) order. Standing orders (also referred to as scheduled orders) are administered routinely as specified until the order is canceled by another order.

Before administration and to ensure safe administration, medication records are strictly on hand at time of administration and medication given according  the “five rights” namely:

  1. Right patient
  2. Right drug
  3. Right route
  4. Right dose
  5. Right time

Documentation of medication administration is an important responsibility. The medication record tells the story of what substances the patient has received and when. Like other health care records, it is also a legal document.

Hospitals usually have policies and procedures regarding documentation of medication administration. Such policies and proceudres would entail that a listing of all current medications taken prior to admission must be recorded in the patient’s medical record and is available to the pharmacy, nurses, and doctors. An established process contained in such medication related procedures may include that this listing of ‘all current medications taken prior to admission’ is readily available so that it can be used to compare with ‘initial medication orders’.

Now, just in case your hospital is been prepared for JCI accreditation, the medical records you keep must comply with two JCI standards to meet its requirements for proper documentation of medication administration.

The first of the two standards mentioned above which your hospital needs to comply with is JCI Standard MMU.4, which states that ‘Prescribing, ordering, and transcribing are guided by policies and procedures.’

Medical, nursing, pharmacy, and administrative staff in your hospital actively collaborate to develop and monitor such policies and procedures.This standard guides the safe prescribing, ordering, and transcribing of medications.

What concerns you as the Health Information Management/Medical Records practitioner directly is the process of transcribing of medications (by doctors, usually the clerking doctor at admission), which includes ‘a listing of all current medications taken prior to admission’ that must be duly recorded in a patient’s medical record, which will then be measurable for complaince by JCI Standard MMU.4, ME 5.

However, do take note your hospital must comply with JCI Standard MMU.4, ME 6 which requires that this listing is important to be maintained in a medical record since it is used to make a comparison between ‘all current medications taken prior to admission’ against ‘initial medication orders’.

The other direct concerns to you when your hospital is been prepared for JCI accreditation is to be beware that your medical records must contain medication documentation as required by JCI Standard MMU.4.3 which states ‘Medications prescribed and administered are written in the patient’s record’ and that this documentation in your medical records have evidence that can show:

  • medications prescribed or ordered are recorded for each patient that is measurable by JCI Standard MMU.4.3, ME 1
  • medication administration is recorded for each dose, measurable by JCI Standard MMU.4.3, ME 2
  • medication information is kept in the patient’s record or inserted into his or her record at discharge or transfer, measurable by JCI Standard MMU.4.3, ME 3

In summary, in case your hospital is been prepared for JCI accreditation, then look out for JCI Standard MMU.4 and its two requirements ME 5 and ME 6, and also JCI Standard MMU.4.3 and its three requirements namely ME 1, ME 2 and ME 3, so that the medical records you keep complys with these two JCI standards and so to meet its five respective requirements for proper documentation of medication administration.

References:
Carol, T, Carol, L & Priscilla, L 1997, Fundamentals of Nursing: The Art of Science of Nursing, 3rd edn, Philadelphia: Lippincott-Raven Publishers

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

Janet, W & Jane, HK 2010, Health assessment in nursing, 4th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

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

Patricia, AP & Anne, GP 1997, Fundamentals of Nursing: Concepts, Process, and Practice, 4th edn, St Louis, USA, Mosby-Year Book, Inc.

Work Not Documented Is Work Not Done