I had posted in the post Risks, benefits, and alternatives of anaesthesia (this link will open in a new tab of your current browser window) on the anaesthesia planning process which includes educating the patient, his or her family, or decision maker on the risks, benefits, and alternatives related to the planned anesthesia and postoperative analgesia. This discussion occurs as part of the process to obtain consent for anesthesia (including moderate and deep sedation). In anaesthesia care, an anesthesiologist or a qualified individual provides this education.when the risks, benefits, and alternatives are discussed with the patient, his or her family, or those who make decisions for the patient.
Likewise prior to surgery, patients and their families or decision makers receive adequate information to participate in care decisions and to provide the informed consent.
The information provided includes:
- the risks of the planned procedure;
- the benefits of the planned procedure;
- the potential complications; and
- the surgical and nonsurgical options (alternatives) available to treat the patient.
In addition, when blood or blood products may be needed, information on the risks and alternatives is discussed.
The patient’s surgeon or other qualified individual provides this information.
Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware that medical records of patients must show evidence of the education process in an ongoing process prior to surgery. Medical records must contain documentation on this process as required by the Joint Commission International (JCI) Standard ASC.7.1 which clearly states that “The risks, benefits, and alternatives are discussed with the patient and his or her family or those who make decisions for the patient.”, and its three (3) Measurable Elements (ME) which must be met fully at hospitals that are JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.
HIM / MR practitioners must also be aware that the Joint Commission International (JCI) Standard PFR.6.4 which clearly states that “Informed consent is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures.” I had posted about informed consent in the post Informed Consents – 5 required documentation in the medical record providing information to patient and family (this link will open in a new tab of your current browser window).
Lastly, HIM / MR practitioners do take note that the JCI Standard ASC.7.1 is checked for compliance in the Medical Record Review Tool form used in the Medical Record Review process if your hospital is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA