From the earlier post Medical documentation in medical records of initial medical and nursing assessments, I wrote about the initial assessment which includes :
- an evaluation of the patient’s medical status through a physical examination and health history
- the psychological assessment determines the patient’s emotional status (for example, if he or she is depressed, fearful, or belligerent and may harm him- or herself or others)
- gathering social information on a patient’s social, cultural, family, and economic contexts are important factors that can influence his or her response to illness and treatment but is not intended to “classify” patients
- inputs from patient’s families providing helpful clues in these areas of assessment and in understanding the patient’s wishes and preferences in the assessment process
- economic factors as part of the social assessment or assessed separately when the patient and his or her family will be responsible for the cost of all or a portion of the care while an inpatient or following discharge
You would have also read from that post, how many different qualified individuals may be involved in the assessment of a patient. The most important factors are that the assessments are complete and available to those caring for the patient.
When the initial assessments are completed and available, the doctor forms and initial diagnosis. The initial diagnosis ia an important part of the medical documentation in a medical record.
For quality assurance purposes, and for benefit of a Health Information Management (HIM) / Medical Records (MR) practitioners working in a hosptial that is actively undergoing an accreditation program for quality assurance and if your hospital is adopting the Joint Commission International (JCI) acrreditation program, do take note that the initial diagnosis is an important medical documentation by a doctor in a medical record and must always be present in a medical record in order to comply with the Joint Commission International (JCI) Standard AOP.1.2, ME 4 which states that “The initial assessment(s) results in an initial diagnosis”.
For your information the JCI Standard AOP.1.2 states that “Each patient’s initial assessment(s) includes an evaluation of physical, psychological, social, and economic factors, including a physical examination and health history.”
Also ensure that all your inpatient and outpatient medical records :
- contain documentation about an initial assessment(s) that includes a health history and physical examination consistent with the requirements defined in hospital policy, thus complying with the JCI Standard AOP.1.2, ME 1
- contain documentation about that each patient had received an initial psychological assessment as indicated by his or her needs, which will then comply with the JCI Standard AOP.1.2, ME 2 ; and
- contain documentation that shows each patient received an initial social and economic assessment as indicated by his or her needs, which will also then comply with the JCI Standard AOP.1.2, ME 3
In summary, your medical records documentation must comply with the JCI Standard AOP.1.2 and its four (4) requirements, if your hospital hopes to meet this JCI accreditation standard of quality of care.
Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA