JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol, latest Medical Records Review Tool

I know that the most frequently viewed post(s) on this blog are regarding Medical Record Review (MMR) using the Joint Commission International (JCI) Accreditation Hospital Standards.

This post is also regarding Medical Record Review. I shall be using ‘Medical Record Review’ rather than ‘Medical Records Review’ from now on to reflect what JCI uses in its manual. I guess this is no big deal, but I shall conform.

I have been using the term MMR Tool (MMRT) but do take note that the MMRT is also referred to as the Medical Record Review Form (MMRF) as in the JCI’s Hospital Survey Process Guide (HSPG).

This post is about the MMRT / MMRF as recommended in the JCI’s HSPG, 4th Edition, Version 2 effective 1 January 2011. All future posts related to the application of the MMRT / MMRF will be based on this latest edition of the JCI’s HSPG.

I have been posting posts related to the application of the MMRT / MMRF (you can view this particular tool /form from this link which will open in a new tab of your current window) as recommended in the JCI’s HSPG, 3rd Edition, effective January 2008.

You can view a sample of the latest MMRT / MMRF from this link, which will open in a new tab of your current window.

The purpose of using the MMRT / MMRF according to JCI (HSPG, 4th edn, p. 70) remains as before, that is to help “validate the hospital’s compliance with the documentation track record”, i.e to also say in JCI’s words (HSPG, 4th edn, p.70) that is “to gather and document compliance with standards that require documentation in the patient’s record”.

Health Information Management (HIM) / Medical Records (MR) practitioners need to know that the MMRT / MMRF is used during closed patient medical record review session(s) in addition to during tracer activities when the same MMRT / MMRF is used during open patient medical record review session(s) using ‘open’ medical records of patients currently staying in the hospital are evaluated.

While I understand that the survey team will provide the latest version of the MMRT / MMRF which will include any approved changes in the standards, a HIM /MR practitioner or the hospital quality assurance (QA) department are usually required to provide the MMRT / MMRF for mock closed or open patient medical record review session(s).

You will notice that both the latest and previous versions of the MMRT / MMRF are organised as follows:

By three (3) topic headings, ‘Consent’, ‘Assessments’ and ‘Other’

  1. Each topic heading includes several standards
  2. Each standard under a topic heading lists the specific standard number e.g ‘ACC.3.2.1’ as listed under topic heading ‘Other’
  3. Each specific standard under a topic heading lists the standard requirement i.e the specific standard’s requirement as will be printed in the ‘Documentation Requirement’ column in the MMRT / MMRF, e.g the standard ACC.3.2.1 requirement is as printed below:

“Discharge summary contains the following:

      • Reason for admission, diagnoses, and comorbidities
      • Significant physical and other findings
      • Diagnostic and therapeutic procedures performed
      • Significant medications, including discharge medications
      • The patient’s condition/status at the time of discharge
      • Follow-up instructions”

During an accreditation survey,  the surveyor(s) – be they be members of the real JCI accreditation survey or members of the hospital’s mock MMR process team, will both use the MMRT / MMRF :

  1. to enter the number of the medical record being reviewed and the type of medical record requested (recorded by diagnosis) on the top of the form, e.g  “Record #1234678  Asthma”)
  2. to review the medical record as according to JCI (HSPG, 4th edn, p. 70) so as “briefly to decide what type of patient or care was received (for example, surgery, medical, emergency, and rehabilitation).”

Other request(s) by the survey team or a typical MMR session by the hospital’s mock MMR process team can be read by reading my previous posts as follows  (each of these links will open in a separate tab of your current window) :

  1. JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol, Medical Records Review Tool
  2. JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA
  3. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 3rd edn, JCI, USA

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