Joint Commission quarterly update Medical record documentation guide and medical record reviews

Transcription

1 April 2016 HIM Briefings Joint Commission quarterly update Medical record documentation guide and medical record reviews Jean S. Clark, RHIA, CSHA Our readers have been asking for an updated medical record documentation guide, and here it is new and improved! The guide provides references to the associated CMS Conditions of Participation and new and revised standards and elements of performance (EP). A recent Joint Commission column discussed ongoing record reviews and the continued focus of Joint Commission surveyors related to documentation in the medical record. The guide takes the Record of Care, Treatment, and Services chapter and breaks it down into an easy-to-use tool for comprehensive record reviews by topic. How to use the guide The guide can be used for open as well as closed medical record reviews. You can provide the appropriate sections of the guide to your clinical documentation specialists, nursing unit managers, operating room staff, patient tracer teams, and others to review medical records while the patients are in the hospital, outpatient settings, or physician offices. The HIM department can perform reviews of medical records at the time of discharge to ensure the records timely completion. Go paperless When possible, go paperless by reviewing EMR documentation. Build the guide into a format that is easy to use, whether you re on a desktop or a handheld device. And, when you can, build hard stops in your EMR to avoid incomplete medical record issues with histories and physicals, operative reports, and other documentation requirements at the point of care. Don t forget: The Joint Commission continues to require ongoing medical record review at the point of care. This guide should help you with this requirement and provide improved documentation for quality and safe patient care. Note: Although the guide is comprehensive, always refer back to the Record of Care, Treatment, and Services chapter for complete information related to documentation in the medical record. A special medical record tool for review of restraint/seclusion will be featured in the next quarterly Joint Commission column. H Use this tool as a guide for ongoing record reviews. Next to each question, note whether the standard was met ( ), not met (X), or not applicable (NA). RC Is there a complete and accurate medical record for each patient? EP 1: Are the components of the medical record defined? (CMS , (b)) A* EP 4: Does the medical record contain information unique to the patient that is used for patient identification? M (Measure of Success) EP 5: Does the medical record contain information to support the diagnosis and treatment for the patient? M (CMS (c), (c)(1), (a)(2), (c)(1)(i), (c)(1)(v), (c)(2), (a)(4)(ii), (a)(4)(iii), (b)(2)) 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 11

2 HIM Briefings April 2016 EP 6: Does the information in the medical record validate the patient s care, treatment, and services? M (CMS (c), (c)(1), (c)(1)(i), (c)(1)(v), (c)(2), (a)(4)(ii), (a)(4)(iii), (b)(2)) EP 7: Does the information in the medical record document the course and result of the patient s care, treatment, and services? M (CMS , (b), (c), (c)(1), (c)(1)(i), (c)(2), (a)(4)(ii), (a)(4(iii), (b)(2)) EP 8: Does the information in the medical record promote continuity of patient care? M (CMS , (b), (c), (c)(1), (c)(1)(iv), (c)(2), (a)(4)(ii), (a)(4)(iii), (b)(2)) EP 9: Are standardized formats used in the medical record? A (CMS (b)(2)) EP 11: Are dates included for all entries? (482.24(c)(1), (d), (c)(2), (d)(2)) EP 12: Does the hospital track all components of the medical record? A (CMS (b)(2)) EP 13: Does the organization assemble or make available in a summary in the medical record all necessary information to provide care, treatment, and services to the patient? M (MM , EP 1) EP 19: Are all entries in the medical record (including orders) timed? (CMS (c)(1), (c)(2)) RC Are all entries in the medical record authenticated? EP 1: Does only authorized staff make entries in the medical record? R**, M (CMS (c)(3)(iii)) EP 2: Are the types of entries made by non-independent practitioners that need countersignatures defined? A, R (CMS (c)(3)(iii), (c)(1), (c)(2)) EP 3: Is the author identified for all entries in the medical record? R, M (CMS (b), (c)(1), (d), (c)(2), (c)(3)(iii), (d)(1), (d)(2)) EP 4: Does the author authenticate information entered into the medical record including transcription or dictation? R, M, D*** (CMS (b), (c)(1), (b)(6), (d), (c)(2), (c)(3)(iii), (c)(3), (d)(1), (d)(2)) Note: Please refer to your accreditation manual for notes related to this EP. Information regarding verbal orders is explained here. EP 5: Is the person identified by a signature stamp or electronic authentication the only user? A, R (CMS (b), (c)(1), (d), (c)(2), (c)(3), (d)(1), (d)(2)) RC Is documentation timely? EP 1: Is there a policy that requires timely entries? (PC , EP 1) A, D (CMS (b)) EP 2: Is the time frame for record completion defined not to exceed 30 days after discharge? A (CMS (b), (c)(4)(viii)) EP 3: Is the timely entry policy implemented? (PC , EP 2) M (CMS (b)) EP 4: Are H&Ps, including updates, recorded within 24 hours after registration or inpatient admission and prior to surgery or procedure requiring anesthesia services? M (CMS (b)(2)(i), (b)(1)(ii), (c)(4)(i)(a), (c)(4)(i)(b)) RC Does the organization conduct medical record reviews? EP 1: Does the hospital conduct ongoing reviews of medical records at the point of care based on presence, timeliness, legibility, accuracy, authentication, and completeness? (MS , EP 3) M (CMS (b), (c)(1)) EP 3: Are medical record delinquency rates regularly measured, but no less than every three months? (MS , EP 3) A EP 4: Does the medical record delinquency rate averaged from the last quarterly measurements equal 50% or less of the average monthly discharge rate? Are individual quarterly measurements no greater than 50% of the average monthly discharge rate? (MS , EP 3) A, D 12 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

3 April 2016 HIM Briefings RC Does the hospital retain its medical record? EP 1: Is the retention time of the original or legally reproduced medical record defined in policy and based on use, law and regulation? A, D (CMS (b), (b)(1), (d)(2)(i), (d)(2)(ii), (d)(2), (d)(1)) EP 8: Are original medical records only released when responding to law and regulation? A (CMS (b), (b)(3)) RC Does the medical record contain information that reflects patient care, treatment, and services? EP 1: Is the following information included in the medical record? R, M, D (CMS (a)(1)) Patient name, address, date of birth, and name of any legally authorized patient representative? Patient s sex? Legal status of a patient who is receiving behavioral health services? Patient s preferred language and communication needs? (PC , EP 1) In cases where the patient is a minor, incapacitated, or has a designated advocate, are the communication needs of the parent, legal guardian, surrogate decision-maker, or legally authorized representative documented in the medical record? EP 2: Is the following clinical information included in the medical record? M Reason(s) for admission, treatment, services? Initial diagnosis, diagnostic impressions, or conditions? Results of assessments and reassessments? (PC , EPs 1 & 4, PC , EPs 1 & 8) Food allergies? Medication allergies? H&P examination, conclusions, or impressions? Diagnosis or condition, including any complications and/or hospital-acquired infections? Consultative reports? Observations relevant to care, treatment, and services? Patient s response to care, treatment, and services? Emergency care, treatment, or services provided prior to patient s arrival? Progress notes? Orders? Medications ordered and prescribed? Medications administered, including strength, dose, and route? Access site for medication, administration devices, and rate of administration? Adverse drug reactions? Treatment goals, plan of care, and revisions to the plan of care? (PC , EPs 1 & 23) Results of diagnostic and therapeutic tests and procedures? Medications dispensed or prescribed at discharge? Discharge diagnosis? Discharge plan and planning evaluation? (see also (PC , EPs 6 8)) 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 13

4 HIM Briefings April 2016 Note: See accreditation manual for related CMS Conditions of Participation for EP 2. EP 4: Does the medical record contain the following information, as needed for care, treatment, and services? R, M (CMS (c)(4)(v), (b)(2)) Advance directives (RI , EP 11) Informed consents? Records of communication, such as telephone calls or s? Patient-generated information? EP 10: For psychiatric hospitals that use The Joint Commission for deemed status, are progress notes recorded by the following individuals involved in the care of the patient? R, M CMS (d) Doctor responsible for care, nurse, social worker, others; and are progress notes recorded at least weekly for the first two months and monthly thereafter? EP 21: Does the medical record for urgent or immediate care patients contain the following? R, M Time and means of arrival? Indication if left against medical advice? Conclusions, including final disposition, condition, and instructions for follow-up care? Is a copy of this information available for the practitioner or medical organization responsible for follow-up care? EP 28: Does the medical record contain race and ethnicity? R, M EP 29: For primary care medical home patients, does the medical record contain patient self-management goals and progress towards goals? A RC Does the medical record document operative and other high-risk procedures, as well as moderate or deep sedation and anesthesia? EP 1: Are the operative or other high-risk procedures and administration of moderate or deep sedation or anesthesia documented in the medical record? A, R CMS (b)(2) EP 2: Does a licensed independent practitioner (LIP) involved in the patient s care document the provisional diagnosis before the patient undergoes an operative or other high-risk procedure? R, M (CMS (b)(6)) EP 3: Is the medical history and physical examination recorded in the medical record before the patient undergoes an operative or other high-risk procedure? (PC , EPs 4 & 5) R, M (CMS (c)(4)(i)(A)) EP 5: Is the operative or other high-risk procedure report written or dictated after the operative or other high-risk procedure is completed and before the patient is released to the next level of care? R, M (CMS (b)(6)) Note: Refer to exceptions in the accreditation manual. EP 6: Is the following information included in the operative or other high-risk report? R, M (CMS (b)(6)) Name of the primary surgeon who performed the procedure and name of any assistants? Name, description, and findings of the procedure? Estimated blood loss? Specimen(s) removed? Postoperative diagnosis? EP 7: Is a progress note entered in the medical record before the patient is transferred to the next level of care? R, M (CMS (b)(6)) 14 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

5 April 2016 HIM Briefings Does the progress note include the following? Name of the primary surgeon who performed the procedure and name of any assistants? Name, description, and findings of the procedure? Estimated blood loss? Specimen(s) removed, if any? Postoperative diagnosis? EP 8: Is the following postoperative information included in the medical record? (PC , EP 1, PC , EP 1) R, M (CMS (c)(4)(iv), (b)(6)) Patient s vital signs and level of consciousness? Any medications, including intravenous fluids and any administered blood, blood products, and blood components? Any unanticipated events or complications and how staff managed those events? EP 9: Does the medical record document that an LIP responsible for the patient s care discharged the patient from post-sedation or post-anesthesia care? If not, does it document that the patient was discharged from the post-sedation or post-anesthesia care based on discharge criteria? (PC , EP 4) R, M EP 10: Does the medical record document that staff used approved discharge criteria to determine the patient s readiness for discharge? (PC , EP 4) R, M EP 11: Does the postoperative documentation include the name of the LIP responsible for discharge? R, M CMS (b)(6) EP 15: Does the hospital have a complete operating room register, including: Patient name? Medical record number? Operation date? Inclusive or total time of operation? Name(s) of surgeons and assistants? Name(s) of nurses? Anesthesia type and name of person administering? Operation? Pre- and postoperative diagnosis? Age of patient? Note: A postoperative summary may be used if all elements are included. M (CMS (b)(5)) RC Is there a summary list for each patient who receives continuing ambulatory care services? EP 1: Is a summary list initiated by the patient s third visit? M EP 2: Is the following information included in the summary list? M Any significant medical diagnoses and conditions? Any significant operative and invasive procedures? Any adverse or allergic drug reactions? Any current medications, over-the-counter medications, and herbal preparations? EP 3: Is the summary list updated whenever there is a change in diagnoses, medications, or medication allergies, or whenever a procedure is performed? M EP 4: Is the summary list readily available? M 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 15

6 HIM Briefings April 2016 RC Do qualified staff receive and record verbal orders? EP 1: Is it in writing who can receive and record verbal orders? A, D (CMS (c)(3)(ii)) EP 2: Does the hospital ensure that only authorized staff members receive and record verbal orders? M (CMS (c)(3)(ii)) EP 3: Do verbal orders include the date and name of staff who gave, received, recorded, and implemented verbal orders? (CMS (c)(3)(ii), (c)(2)) EP 4: Are verbal orders authenticated within the time frame required by law and regulation? (CMS (c)(3)(ii), (c)(2),482.23(c)(3)) EP 6: Do verbal orders include the time the verbal order was received? (CMS (c)(3)(ii), (c)(2)) RC Is the patient s discharge information documented? EP 1: For hospitals with swing beds, is there discharge information provided to the resident (patient) and/or receiving hospital? M (CMS (a)(3), (a)(3)(i), (a)(3)(ii), (b)(2)) EP 2: For hospitals with swing beds, does the discharge information include: M (CMS (a)(3), (a)(3)(i), (a)(3)(ii), (b)(2)) Reason for transfer, discharge, or referral? Treatment provided, diet, medication orders, and orders for immediate care? Referring LIP s name, and name of LIP who will be responsible for the care? Findings and diagnoses, summary of care, and progress toward goals? Reason for hospitalization? Information about behavior, ambulation, nutrition, physical status, psychosocial status, or potential rehabilitation? Useful nursing information? Advance directive? Discharge instructions? EP 3: Is there a discharge summary that includes: M (CMS (c)(4)(vii), (e) Note: This is for all patients other than swing bed patients. Also refer to accreditation manual for exceptions to the discharge summary. Reason for hospitalization? Procedures performed? Care, treatment, and services provided? Patient s condition and disposition at discharge? Information provided to the patient and family? Provisions for follow-up care? *A: Scored as A EP and requires 100% compliance **R: Risk-stratified EP ***D: Documentation required All other EPs are scored as C EPs and require 90% compliance. At a minimum, you should review the R (risk-stratified) EPs. Ongoing record reviews at the point of care are still required. See RC HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or