JCI Standard MCI.13 – Use of standardised symbols and abbreviations

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The Joint Commission International (JCI) Standard MCI.13 is about the uniform use of standardised diagnosis codes, procedure codes, symbols, abbreviations (which includes a “do not use” listing), and definitions in a hospital which supports data aggregation and analysis and which facilitates comparison of data and information within and among organisations by using such standardised terminology, definitions, vocabulary, and nomenclature consistent with recognised local and national standards.

I shall be writing in the context of what a Health Information Management (HIM) / Medical Records (MR) practitioner on a need-to-know and what-to-do basis about this standard and its intent. To write all about the intents of this standard will take several posts, and I do not wish to be publishing text-book material here. I only plan to blog about what you need to know as an HIM/MR practitioner and what you need to plan and implement for your role as a HIM/MR practitioner, from the perspective of a quality practitioner with the background of as a HIM/MR practitioner.  I do not intend to publish a long posts, so this post is all about an official (approved) abbreviation list and the first post of a series of posts on the JCI Standard MCI.13, perhaps covering 2 or 3 more posts.

I believe every hospital  should establish a policy to maintain an official (approved) abbreviation list as to which abbreviations, acronyms, and symbols (and their meanings) can be documented in the patient record.

One does not wait for his or her hospital to be seeking JCI or other agency hospital quality assurance accredited status before embarking on a policy and an approved abbreviation list.

Here I am listing tasks for the HIM/MR practitioner and the Medical Records Committee (MRC) of a hospital :

  1. the HIM/MR practitioner should initiate an approved abbreviation list for discussion during a MRC meeting if he or she finds there in no approved abbreviation list or if the existing one needs a much-needed revision
  2. the MRC should set a dateline for medical-staff of the hospital to review and submit a revised list by distributing the existing list
  3. if there is no existing list, the HIM/MR practitioner should source for a sample list which can be downloaded from many Internet websites (check for copyright information; if written permission is required to reproduce, then it is wise to write to the copyright owner)
  4. modify and customise for local use, present at the MRC meeting and if approved for distribution, distribute to medical-staff of the hospital to review and submit a revised list by a set dateline
  5. the revised abbreviation list of an existing list or a newly created abbreviation list after review should be presented to the MRC
  6. the Chairman of the MRC who is usually a clinician, would then make it easier the task of final approval of this abbreviation list by using his or her influence among fellow clinicians in all medical disciplines of the hospital for consensus
  7. the abbreviation list is deemed finally an approved abbreviation list after one last meeting agenda to approve it officially at a scheduled MRC meeting
  8. the abbreviation list is forwarded to the hospital top management for final approval and signature before it is formated in an appropriate format and printed for distribution to all disciplines and patient care areas of the hospital
  9. a hospital policy must be created by the HIM/MR practitioner to document the approved abbreviation list as to which abbreviations, acronyms, and symbols (and their meanings) can be documented in the patient medical record of the hospital.

If your hospital is already JCI accredited, I am taking a guess the Management of Communication and

Information (MCI) Committee (MCIC) which has oversight on all matters pertaining to MCI, had initiated the approved abbreviation list of a revised existing list or created a new approved abbreviation list. The MCIC notifies the MRC about the necessity for compliance to JCI Standard MCI.13, and the MRC carries out tasks outlined as above for a hospital already JCI accredited or a hospital seeking JCI accreditation.

Usage of abbreviations, acronyms, and symbols found in the medical record during routine and/or random checks is monitored by the HIM/MR Department for any hospital. For JCI accredited or JCI accreditation seeking hospitals, checks are also done during a Medical Records  Review process session(s) and unapproved abbreviations, acronyms, and symbols  checked against an approved abbreviation list are documented and reported in a report to the Medical Records  Review Committee (MRRC) which in turn then forwards its meeting minutes highlighting anomalies from the report to the MCIC. The MCIC sends in a report or a letter to the MRC Chairman for his or her attention and appropriate action.

Before I end this post, I need to say that the JCI standards have not explicitly required an approved list of abbreviations. However, a “do not use” list which is a  “(JCI 2011) written catalog of abbreviations, acronyms, and symbols that are not to be used throughout a hospital – whether handwritten or entered as free text into a computer – due to their potentially confusing nature”, it is appropriate that a “do not use” list forms a part of the approved abbreviations list. You can view the Official Do Not Use List as it stands today released in 2004 by the Joint Commission (UnitedStates)  after you download it from
http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf (this link will open in a new tab of your current browser window).

My post on an approved abbreviation list ends here, and allow me to continue in my next post more on other concerns of the JCI Standard MCI.13

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

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

HIM Career Map©

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I am sure many Health Information Management (HIM) practitioners in the U.S. and HIM practitioners from the U.S. who are following this blog already know about an innovative tool for charting their promotional pathways. I had kept away this article after reading a news feed about it a few days ago, and wanted to toy around with this interactive tool before I could blog about it today.

In the U.S., the U.S. Bureau of Labor Statistics expects employment in the medical record and Health information Management (HIM) field to increase 21 percent by 2020.

With this expected growing demand for qualified HIM professionals high and for both HIM students and professionals seeking to chart their career course in the rapidly changing field of HIM, the American Health Information Management Association (AHIMA) representing more than 64,000 specially educated Health Information Management professionals in the United States and around the world has unveiled  Health Information Management (HIM) Career Map©.

This HIM Career Map© is a one-stop place to learn about HIM careers, where the field is now and where it is heading. Claimed as the first career map of its kind in the healthcare profession, it was made possible by working in a partnership between the AHIMA Foundation and the Center for Adult and Experiential Learning (CAEL) and in part by philanthropic contributions from Career Step – “a leading online school with almost 20 years of experience providing career education specifically designed to help students gain the knowledge and skills needed to quickly transition to a successful career after graduation.” (Career Step 2012).

The HIM Career Map© is an interactive and visual representation of 53 current HIM job titles and roles that compose the scope of the field and 14 emerging roles in HIM arranged in a grid with six broad job families on the top row and four skill levels on the left side of the grid.

Any white dot in any square of the grid represents each HIM job title while a yellow diamond in any square of the grid represents an emerging HIM job title. Clicking on a white dot displays a rounded rectangle box pointing to the chosen HIM job title white dot. This box shows a description and details on the skills required, job responsibilities, education and work experience needed for success, and promotional pathways. More detailed description on this HIM job title can be viewed by clicking on  the yellow box labeled ‘FULL DESCRIPTION’ at the bottom of the rounded rectangle box. Simultaneously, line(s) radiate from this white dot to other white dots or yellow diamonds representing promotional HIM job title(s) in neihbouring squares of the grid .

The following screenshots show three (3) views of this map. A larger view of each screen shot opens in a new tab of your current browser window.

introduction screen

Grid showing skill levels on the left, broad job families on top row,white dots for existing HIM titles and yellow diamonds for emerging HIM titles

HIM job title box and radiating lines to adjacent HIM job titles

The HIM Career Map© also indicates alternate titles for some positions due to the different terminology used in the industry. The map is driven by data from AHIMA subject matter experts, staff and an AHIMA member survey.

For full details of the HIM Career Map©, visit http://hicareers.com/CareerMap/ (this link will open in a new tab of your current window).

AHIMA hopes that the map will help students, recent graduates and HIM professionals looking for new opportunities to plan a path to success through the promotional and transitional career paths associated with them.

AHIMA plans to add emerging roles to the map as needed to reflect the current reality of HIM roles, pathways between the roles and connections to the direction in which the profession is moving.

I think this tool is simple yet a clever plan to graphically display HIM job titles and career pathways in a grid, and qualifies as a one-stop quick resource center and  reference portal to check on HIM opportunities in the U.S.

References:
Career Step, viewed 5 July 2012 <http://www.careerstep.com/about-us>

Health Information Careers – Career Mapping, viewed 5 July 2012 <http://hicareers.com/CareerMap/>

Diagnostic procedures

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A Health Information Management (HIM) / Medical Records (MR) practitioner will find a series of diagnostic tests or diagnostic procedures – terms used interchangeably, incorporated into the medical record of a patient.

Diagnostic tests or procedures are necessary to formulate a medical diagnosis and the course of treatment based on a patient’s history and presenting symptoms. Diagnostic tests or procedures are also performed to determine abnormalities or disorders of various body systems to identify and to prioritise the treatments and procedures during periodic reassessment and evaluation of the patient’s expected outcomes.

In the post Plan Of Care (this link will open in a new tab of your current window) about individualised care plans, you can read to know about a patient’s care plan which is always related to his or her identified needs. But those needs may change as the result of clinical improvement or new information from a routine reassessment, for example from diagnostic tests such as abnormal laboratory or radiography results.

As diagnostic tests or procedures are expensive, they are prescribed usually selectively by the prescribing practitioner, who is either the doctor in most instances or other authorised  prescribing practitioners like advanced practice registered nurses who are authorised to order and perform certain diagnostic tests.

Diagnostic tests or procedures are either noninvasive or invasive. Noninvasive means the body is not entered with any type of instrument. The skin and other body tissues, organs, and cavities remain intact. Invasive means accessing the body’s tissue, organ, or cavity through some type of instrumentation procedure.

If you are working as a HIM/MR practitioner in a Joint Commission International  (JCI) accredited hospital or a hospital seeking JCI accredited status or infact at any hospital, the medical records show documentation evidence of doctors who had found an abnormality and had prescribed diagnostic tests or procedures to evaluate findings more closely. The JCI Standard COP.2.3 requires that such evidence be demonstrated in the patient’s medical record.

As the JCI Standard COP.2.3 intent statement specifically lists endoscopy and cardiac catheterisation diagnostic procedures, I shall provide some brief details on these diagnostic precudures.

Endoscopy is an invasive diagnostic technique using specialised instruments called endoscopes such as the sigmoidoscope, colonoscope, gastroscope, bronchoscope, and laryngoscope, for visual observation of internal organs through the intestinal tract. However, no incisions are made for routine endoscopy procedures.

 A team of doctors, nurses, and technicians perform a cardiac catheterisation procedure, which takes from 1 to 3 hours to obtain information about congenital or acquired heart defects, measure oxygen concentration, determine cardiac output, or assess the status of the heart’s structures and chambers. Therapeutic treatments may be done during the catheterisation to repair the heart, open valves, or dilate arteries.

Whatever the reason for diagnostic tests or procedures, diagnostic tests or procedures performed and the diagnostic findings (results) are always incorporated into the patient’s medical record. Such documentation on the appropriate forms will indicate details like the identity of the prescribing practitioner and his or her reason for performing the diagnostic and other procedures, if he or she had administered any anesthesia, dye, or other medications, type of specimen obtained and where it was delivered, vital signs and other assessment data such as patient’s tolerance of the procedure or pain and discomfort level as well as any symptoms of complications, patient or family teaching and demonstrated level of understanding  and written instructions given to the patient or family members about the diagnostic and other procedures.

A HIM/MR practitioner must will be able to differentiate between diagnostic and other procedures performed and the location of their diagnostic findings(results) from that for surgical procedures, a written surgical report or a brief operative note that can be found in the patient’s medical record.

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

Michelle AG & Mary JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

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

Anaesthesia plan in the patient’s medical record

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A Health Information Management (HIM) / Medical Records (MR) practitioner will find documentation of preoperative activities including each patient’s anaesthesia care which is planned and documented in the patient’s record.

The Joint Commission International (JCI) Standard ASC.5 specifically requires documentation of preoperative activities to include that each patient’s anaesthesia care is planned and documented in the patient’s medical record.

This is true for all patients in the preoperative phase in all hospitals, and not just for hospitals already JCI accredited or seeking JCI or other healthcare quality standards.

After the preoperative evaluation by an anaesthesiologist or another qualified individual as outlined in the post Anesthesia care must be given by a qualified individual (this link will open in a new tab of your current window), anaesthesia care is carefully planned and the anaesthesia plan is created,

The plan includes a list of drug choices and doses in detail, the method of administration, other medications and fluids, monitoring procedures, and anticipated postanesthesia care.

An HIM) / MR practitioner will find documentation of each patient’s anaesthesia care plan as shown in the sample General Anaesthesia Plan below documented in the patient’s medical record.

SAMPLE GENERAL ANAESTHESIA PLAN

Case
A 47-year-old woman with biliary colic and well-controlled asthma requires anaesthesia for laparoscopic cholecystectomy.

Preoperative Phase
Premedication
Midazolam, 1-2 mg IV, to reduce anxiety
Albuterol, two puffs, to prevent bronchospasm

Intraoperative Phase
Vascular access and monitoring
Vascular access: one peripheral IV catheter
Monitors: pulse oximetry, capnography, electrocardiogram, non-invasive blood pressure with standard adult cuff size, temperature
Induction
Propofol, 2 mg/kg IV (may precede with lidocaine, 1.5 mg/kg IV)
Neuromuscular blocking drug to facilitate tracheal intubation (succinylcholine, 1-2 mg/kg IV) or nondepolarizing neuromuscular-blocking drugs (rocuronium, 0.6 mg/kg)
Airway management
Facemask: adult medium size
Direct laryngoscopy: Macintosh 3 blade, 7.0-ID endotracheal tube
Maintenance
Inhaled aesthetic: sevoflurane or desflurane
Opioid-fentanyl: anticipate 2-4 mg/kg IV total during case
Neuromuscular blocking drug titrated to train-of-four monitor (peripheral nerve stimulator) at the ulnar nerve*
Emergence
Antagonize effects of nondepolarizing neuromuscular blocking drug: neostigmine, 70 mg/kg, and glycopyrrolate, 14 mg/kg IV, titrated to train-of-four monitor
Antiemetic: dexamethasone, 4 mg IV, at start of case; ondansetron, 4 mg IV, at end of case
Tracheal extubation: when patient is awake, breathing, and following commands
Possible intraoperative problem and approach
Bronchospasm: increase inspired oxygen and inhaled aesthetic concentrations, decrease surgical stimulation if possible, administer albuterol through endotracheal tube (5-10 puffs), adjust ventilator to maximize expiratory flow

Postoperative Phase
Postoperative pain control: patient-controlled analgesia – hydromorphone, 0.2 mg IV; 6-minute lock-out, no basal rate
Disposition: postanesthesia care unit, then hospital ward*Nondepolarizing neuromuscular blocking drug choices include rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium.

*Nondepolarizing neuromuscular blocking drug choices include rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium.

Source : Ronald DM & Manuel CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA

Do take note that sometime the anaesthesia plan may require modification of the plan which may include a specific requirement for an individual patient and thus may have implications for preparing additional equipment in the operating room for example, special equipment that may be kept in a cart dedicated to difficult airway management or in another instance, the patient’s responses to anaesthesia and surgery may also cause the anaesthesia plan to be adjusted.

When each patient’s anaesthesia care is planned and documented in the patient’s record, then you can be sure that medical record fully meets the two requirements of JCI Standard ASC.5

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

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Ronald, DM & Manuel, CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA

24 beds to go at Morriston Hospital, Wales – a casemix exercise

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I have not blogged about casemix yet, and with this post I intend to kick-start my attempt to share my comments, opinions, views on how health management everywhere have changed the way of doing things in hospitals by applying casemix ideas as an information tool involving the use of scientific methods to build the classifications of patient care episodes by classifying patients into classes or groups which are both clinically coherent and resource homogenous.

I learned about a news article from the South Wales Evening Post about how health management in Wales intends to change the case mix in their hospitals, because they claimed that the existing service is splintered between various sites and therefore inefficient.

To better understand the situation there, I ran an Internet check of healthcare services in Wales, so I could better comprehend what the article was reporting, and to focus on how casemix ideas were applied to bring about the changes at Morriston Hospital, Princess of Wales Hospital, Neath Port Talbot Hospital, and Singleton Hospital, namely the hospitals referred to in the article.

In Wales, seven Local Health Boards (LHBs) are responsible for planning and securing delivery of primary, community, secondary care services, and also the specialist  services for their areas. Abertawe Bro Morgannwg (ABM) University Health Board is one of the largest Health Boards in Wales. It is responsible for three localities – Swansea, Neath Port Talbot and Bridgend areas (see map below of all Hospitals in these ABM localities).

Map credit : Abertawe Bro Morgannwg (ABM) University Health Board

It covers both primary (GPs, pharmacies, dentists and optometrists etc) and secondary (hospitals) care.

Photo credit : http://www.thisissouthwales.co.uk/

Morriston Hospital (left) covers the same geographical area as the City and County of Swansea and has around 750 beds. Morriston Hospital is the site of the major Accident and Emergency Department for Swansea and, with its accessibility to the South West Wales population, is recognised as the Major Trauma Centre for South West Wales.


Photo credit : http://www.wales.nhs.uk/

Princess of Wales Hospital (right) is a district general hospital located on the outskirts of Bridgend town in South Wales. This hospital provides a comprehensive range of acute surgery and medicine for patients of all ages, including inpatient, outpatient and day services, including Accident and Emergency Services.


Photo credit : http://www.thisissouthwales.co.uk/

Neath Port Talbot Hospital (left) has 270 beds and provides a range of inpatient, outpatient and day case services for the people of Neath and Port Talbot.


Photo credit : http://www.thisissouthwales.co.uk/

Lastly, Singleton Hospital (right) is a modern District General Hospital with 550 beds situated on Swansea Bay, adjacent to the campus of Swansea University.


Health authorities in the ABM localities plan to lose hospital beds as a result of a shake-up of health services due to take place during September or October 2012, although the planning for them had already started. As a result, Morriston will lose 23 beds and Singleton, 1 bed.

Health authorities think advances in patient care mean they no longer need as many beds as were necessary in the past.

The change of the case mix in the hospitals served by ABM will change as follows :

  1. Morriston Hospital will to continue to deal with emergency cases, along with Princess of Wales in the Bridgend  area
  2. Morriston Hospital will take care of all complicated elective (pre-planned) orthopaedic operations from across the ABM area
  3. At the moment trauma and orthopaedics are also carried out at Neath Port Talbot Hospital;
  4. Trauma and orthopaedics will no longer be carried out at Neath Port Talbot Hospital but will become a centre of excellence for short-stay orthopaedic surgery

Patients who have had complicated surgery in the two acute hospitals (Morriston and Princess of Wales hospitals) will, as soon as they are well enough, be moved for rehabilitation in Singleton, Neath Port Talbot and Princess of Wales hospitals, depending on where they live; this will free up beds at Morriston for trauma and complex surgery, and it will also mean patients will recover closer to their homes and families.

The drive to rehabilitate results in quick turnover, and hopes to enhance the recovery process after surgery which in turn will lead to better outcomes and reduced readmission rates. For example, if patients have to travel to Morriston or Bridgend for major joint replacement the time they will be there will be much shorter. This according to Phillip and Julie 2011, patients with greatest needs are treated preferentially (vertical access equity as according to Phillip and Julie 2011).

ABM said the aim was to establish a level of care across the board area so that, no matter where people were from, patient health needs are treated alike (horizontal access equity as according to Phillip and Julie 2011).

Health chiefs in the ABM Area have insisted as long as the patient flow was right, the changes in trauma and orthopaedics do not represent any reduction of the service by withdrawing the service and by losing some beds. They also insisted cost-cutting was not the objective of this patient care exercise, but to actually lead to improvement in patient outcomes and pathways for specific patients, particularly the frail and elderly, who have fractured neck of femurs. ABM says that, in the past, elderly patients with serious fractures tended to spend a long time in hospital and their condition deteriorated, sometimes fatally.

ABM has also flagged up the need to strengthen links with social services, particularly to ensure elderly patients who need support at home are not stuck in hospital longer than necessary.

This case mix exercise in Wales seemed like a good idea given the reduction in beds. ABM remained confident there would be a sufficient number of beds to run the service and they could manage as they had built-in some capacity to expand if they do have a busy time.

ABM believes the change in casemix among its hospitals is sensible from all angles – finance, and patient care and also resolving ABM’s significant issues with junior doctor cover. I think the change in casemix has allowed for meaningful comparison of activity between hospitals managed by ABM in Wales.

Internet sources:
Abertawe Bro Morgannwg (ABM) University Health Board , viewed 30 July 2012, <http://www.wales.nhs.uk/sitesplus/863/home>

Phillip B & Julie B 2011, Casemix for Beginners, viewed 15 July 2012, <http://casemixconference2011.com.au/LiteratureRetrieve.aspx?ID=103882>

Abridged by R. Vijayan from an original article in the South Wales Evening Post, July 19, 2012