Assessments before Anesthesia or Surgery

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Preoperative assessment is the assessment done before surgery, i.e the phase when a patient is prepared for surgery in the time span that includes preparation for, the process of, and recovery from surgery.

Gathering of prompt and accurate initial medical assessment information about the patient before surgery helps to ensure a successful outcome for the patient.

This information gathering is largely a nursing function, with assessments also done by the surgeon, the anesthesiologist or a registered nurse anesthetist (RNA).

What you need to know as a Health Information Management / Medical Records practitioner is that patients for whom surgery is planned have a medical assessment performed before the anesthesia or surgery as required by the JCI Standard AOP.1.5.1, ME 1, and this medical assessment of surgical patients is documented in the medical record before surgery as required by the JCI Standard AOP.1.5.1, ME 2.

Maybe it is good to know what kind of data is gathered in an initial medical assessment before anesthesia or surgical treatment.as required by the the JCI Standard AOP.1.5.1 and what goes into the medical record you keep.

Assessment before aneasthesia or surgery includes :

  • observations by the nurse – any unusual reactions or observations recorded in the patient’s medical record and reported to the charge nurse or surgeon at once
  • vital signs the morning of surgery and any significant deviation from normal recorded and reported
  • a general systems review, noting in particular any new cardiopulmonary developments that place the patient at highrisk during surgery
  • a complete physical examination, including laboratory tests and their results recorded in the patient’s record and, if abnormal, reported to the surgeon or their representative – for nonemergency surgery, laboratory tests done about a week before the procedure.

Routine, preoperative laboratory tests often include :

  • a chest x-ray
  • complete blood count (CBC)
  • urinalysis (UA)

Other laboratory tests and examinations will include:

  • a metabolic panel
  • a toxicology screen, if there is a possibility of alcohol or drug abuse.
  • a pregnancy test may be done, to determine what, if any, medication can be used. are performed as needed
  • an electrocardiogram is usually obtained for all patients older than 40 years
  • blood is drawn for a type and cross match if any possibility exists that a blood transfusion will be needed during surgery
  • patient’s weight is documented in kilograms, because dosages of medications, including anesthetics, are usually calculated on the basis of the patient’s kilogram weight
  • a visit from the anesthesiologist or nurse anesthetist (RNA) before surgery enables a patient to ask questions that may be troubling him or her and allows the anesthesiologist or RNA to assess the patient based on the assessment findings listed above – “patient management by anesthesiologists is generally highly standardized and includes some of the most robust safety engineering found in health care”, (ACMQ 2010).

As I end this post, I wish to record that this posting brings back memories of my multifaceted experiences, skills acquired and the joy when I worked as a medical assistant (an equivalent to a male nurse) in my start-off, one singular career phase of my life.

References:
American College of Medical Quality, 2010, Medical quality management : theory and practice, 2nd edn, Jones and Bartlett Publishers, Sudbury, MA, USA

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

JCI Standard MCI.2 – Communication with Patients and Families, about care and services and how to access those services

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JCI Standard MCI.2 states clearly that “The organization informs patients and families about its care and services and how to access those services.”, thereby a hospital must meet 3 of its requirements to match this standard.

Let us now see what a hospital must do to live up to the expectations and hopes of sick patients and their families when they get to a hospital.

Organisation ethics requires that a hospital offer to inform patients and their families complete information they wish to know on the care and services at the hospital. Patient and families have a right to reasonable access to care as well as how to access those services. Information provided also includes information on the proposed care for a patient.

This openness and trustworthiness shown by a hospital when it works to build and establish trust and open communication with patients and their families, and when it also trys to understand and protect each patient’s cultural, psychosocial and spiritual values, helps create a bond between patients and their families.

Let’s now see how the Joint Commission International quality standards fits into this picture of openness by a hospital.

By providing all the needed information with the openness of the hospital, awareness and knowledge gained and learnt of the care and services through this openness, trust bonded between patients and their families and the hospital, the hospital easily complies with two of the JCI Standard MCI.2 requirements  namely ME 1 and ME 2.

If the hospital includes information on the proposed care for a patient.in its initial plan to inform patients and their families, then the hospital meets the requirement by the JCI Standard ACC.1.2, ME 2

At the hospital, it is only normal when patients and their families learn of the hospital’s capability to match their expectations of care and services.

When patients and their families learn that their needs fall beyond the scope of  the hospital’s competence, mission and capabilities, then the hospital is obligated to provide information to the patient and their families on alternative sources of care and services. Such alternative sources of care and services may be available at another hospital in the district, and the hospital then co-ordinates with the other hospital with the needed services, and ensures that such patients are appropriately referred to the other facility with services that meets their ongoing care needs.

The hospital will thus comply with the JCI Standard MCI.2 requirement ME3 if the hospital is able to provide information to the patients and their families on alternative sources of care and services when their needs fall beyond the scope of  the hospital’s competence, mission and capabilities.

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

Paying the high price for ICD-10 compliance when using EMR systems in US hospitals

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Lucky for us in Malaysia, our hospitals with EMR systems with technology already incorporating the ICD-10 code set, are not up against paying the high price of implementing ICD-10 unlike in the US where hospitals using EMR/EHR systems are gearing up for the October 2013 ICD-10 dateline (which is likely to be delayed again to October 2014).

One example of an US hospital system that encompasses 14 hospitals, is the North Shore Long Island Jewish Health System, N.Y. They estimate the price tag will be about US$50 million (about RM158 million) including project management, I.T. remediation(some 90 applications), training and other areas.

Sutter Health which runs 24 hospitals across northern California, is another example which provided an even higher price tag–well over $100 million (about RM316 million), including $60 million (about RM190 million) for technology remediation (some 146 applications will need to be remediated) and $25 million (about RM79 million) for a computer-assisted coding program

Both these organizations are said to well ahead of the rest of the industry in their ICD-10 planning in the US. However, they are being cautious and concerned with  long-term financial impact on their revenue when converting past billing claims to ICD-10 and also estimating where documentation would need to be enhanced to support the more granular codes in ICD-10.

In the US, ICD-9 codes have been used mainly for billing, historically. It seems every clinical encounter that gets billed to an insurance payor includes diagnosis designations, encoded as ICD-9 codes.

Thus, I can understand the profound impact of paying the high price of implementing ICD-10 in the US when changing the fundamental method of encoding diagnoses to a whole new system .

The rationale for making such a change (given the disruption that will occur) is that the ICD-10 code set is more detailed and extensible, allowing for more than 155,000 different codes, and permits the tracking of many new diagnoses and procedures (a significant expansion on the 17,000 codes available in ICD-9).

As we know ICD-10 was developed by the WHO and released in 1992, soon after the ICD-10 system was adopted relatively swiftly in most of the world including in Malaysia.

Abridged, from the article The High Price of ICD-10 by Gary Baldwin, June 26, 2012, Health Data Management reporting  from the HFMA conference June 24-27 2012 in Las Vegas, where panelists shared the above estimates.

With additional references from:
practicefusion.com/, Website
ehrscope.com, Blog
pdmanesthesia.com/, Blog for the image in this post

The Five Rights of Data Administration!

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If you read the post Documentation of medication administration in medical records, I am sure you did not miss reading about how clinicians and nurses use the “Five Rights of Medication Administration” to ensure proper patient care.

If you work in an EMR environment, then the following infographic, entitled “The Five Rights of Data Administration,” created by Symantec to help Health IT staff and users like you, Health Information Management(HIM) / Medical Records (MR) practitioners answer important questions about the use, access, and availability of critical patient data. This infographic outlines specific best practices to ensure that patient information is kept secure regardless of where it is. The infograhic also helps you and Health IT staff in organizations like the hospital you work in better understand the administration of patient data

I believe HIM/MR practitioners working in an EMR setting need to adopt similar but modified best practices for ensuring proper security and privacy for patient data based on the specific best practices outlined in this infograhic.

Note: Click on the infograhic above to view a larger image in a new tab of your current window.

From this infograhic, you need to cultivate the following specific best practices with coordination, guidance and help from IT staff of your hospital.

  1. Right Time – data in EMRs should be available to authorised personnel in your department whenever they need it and must be backed up and secure
  2. Right Route – users like clinicians who need access to EMR data regardless of where they and the device they’re using, must have ready access to updated data your are responsible for at your end
  3. Right Person – ensure only the right people have access to certain information though access verification in your department
  4. Right Data – prevent unauthorised tempering or accidental corruption of data with only users entitled or authorised to have access to data in your department and minimising or banning Bring Your Own Device (BYOD) mobile devices
  5. Right Use – ensure only the “minimum necessary” information is provided to external sources who request data that can be extracted from your end of the EMR system, thus assuring confidentiality

Just like medication administration is taken very seriously with the utmost accuracy and attention to detail as they can mean the difference between life and death, the proper administration of patient data should also be taken very seriously as it too can prevent misdiagnoses or mistreatment without accuracy and attention to detail.

Documentation of medication administration in medical records

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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