2010 Medical Records Documentation Guide

2010 Medical Records Documentation Guide
√ - met X – not met N/A – not applicable
Joint Commission Standard/EP / Record Number
Medication Management (MM)
MM.01.01.01- Is there a written policy outlines the following information will be accessible to LIPs and staff who are managing the patient’s medications? Does the medical record reflect the following:
-  Age and sex?
-  Diagnoses?
-  Allergies?
-  Sensitivities?
-  Current medications?
-  Height and weight (when necessary)?
-  Pregnancy and lactation information (when necessary)?
-  Laboratory results (when necessary)?
-  Any additional information as required by the organization?
Medical Staff (MS)
MS.05.01.03 – Does the medical staff participate in organization-wide performance improvement?
·  Does the medical staff review medical records for accuracy, timeliness and legibility?
Provision of Care, Treatment, and Services (PC)
PC.01.02.01, EPs 1 & 4 – Does the hospital assess and reassess its patients?
·  Is there a policy that defines the scope and content for screening, assessment and reassessment information?
·  Does the initial assessment include the following?
-  Physical, psychological, and social assessment?
-  Nutrition and hydration status?
-  Functional status?
-  For end-of-life care patients, are the social, spiritual, and cultural variables that influence the patient’s and family members” perception of grief assessed and documented?
PC.01.02.03, EPs 4, 6, 7, 8 – Are assessments and reassessments performed according to defined timeframes?
·  H&P examination no more than 30 days prior to, or within 24 hours after registration or inpatient admission? Before surgery or a procedure requiring anesthesia?
·  Nursing assessment within 24 hours after inpatient admission?
·  Nutritional screening within 24 hours after inpatient admission?
·  Functional screening within 24 hours after inpatient admission?
PC.01.02.07, EPs 1 & 3 – Does the hospital assess pain?
·  Is a comprehensive pain assessment performed?
·  Is pain reassessed?
PC.01.03.01, EPs 1 & 23 – Does the hospital plan care?
·  Is the patient’s care planned based upon assessment, reassessment, and results of diagnostic testing?
·  Are plans and goals revised based on patient’s needs?
PC.03.01.03, EPs 1 & 8 – Is care provided before initiating operative or other high-risk procedures, including those with deep sedation or anesthesia?
·  Is there a pre-sedation or pre-anesthesia assessment documented in the medical record?
·  Is there documentation in the medical record that the patient is re-evaluated immediately before administering moderate or deep sedation or anesthesia?
PC.03.01.05, EP 1 – Does the hospital monitor the patient during operative or high-risk procedures and/or moderate or deep sedation?
·  Is there documentation in the medical record that the patient’s oxygenation, ventilation and circulation are monitored during operative or high-risk procedures and/or moderate or deep sedation?
PC.03.01.07, EP 1 and 4 – Is care provided after operative or other high-risk procedures and/or moderate or deep sedation?
·  Is the patient’s physiological status assessed immediately after operative or other high-risk procedure s and/or moderate or deep sedation?
·  Does a qualified LIP discharge the patient from recover? If not is criteria used and documented?
PC.03.02.05, EPs 1 & 2 – Is there an order or approved written protocol documented for non-behavioral health purposes to be initiated restraints?
·  Does an LIP issue the order? If not available, does the RN initiate use based on an assessment of the patient?
·  Does the RN immediately notify the doctor?
PC.03.02.07, EP 1& 2 – Are patients monitored who are in restraints for non-behavioral health purposes?
·  Is the frequency and extent of monitoring determined by the following?
-  Policies and procedures?
-  Protocols?
-  Individual orders?
-  Care setting?
-  Individual patient needs?
-  Laws and regulations?
·  Are patients in restraints for non-behavioral purposes monitored every two hours or more frequently if required by the patient’s needs and policy?
PC. 03.03.07, EP 5 – Are staff competent in minimizing the use of restraint and seclusion for behavioral health purposes?
·  Do authorized staff who perform 15-minute assessments of patients in restraint or seclusion for behavioral health purposes receive ongoing training and demonstrate competence in recognizing the patient’s readiness for discontinuing restrain or seclusion?
PC.03.03.13, EPs 1, 2, 3 – Does a LIP order the use of restraint or seclusion for behavioral health purpose?
·  Does the LIP primarily responsible for the care of the patient order the use of restraint or seclusion?
·  Does qualified staff perform the following within one hour if an order is initiated without an order by the LIP?
-  Notify the LIP?
-  Obtain an order?
-  Consult the LIP about the patient’s physical and psychological condition?
·  Does the LIP guide staff in identifying ways to help the patient regain control to be able to discontinue restraint or seclusion?
·  PC.03.03.17, EP 1 – Are verbal and written orders for restraint or seclusion time-limited?
-  Four hours for patients ages 18 or older?
-  Two hours for patients ages 9 to 17?
-  One hour for patients under age 9?
PC.03.03.25, EPs 1 & 2 – Are patients who are in restraint or seclusion monitored?
·  Monitored by continuous in-person staff competent and trained to do so?
·  For patient in physical hold for behavioral health purposes, another staff person who is trained and competent in the use of restraint and seclusion and not involved in the physical hold observes the patient?
PC.03.03.29, EP 1 – Are patients debriefed after use of restraint or seclusion?
·  Is a debriefing held with the patient and staff who participated in their use held after each episode of restraint or seclusion? Is this based on the plan of care? The patient’s family?
Record of Care, Treatment and Services (RC)
RC.01.01.01 – Is there a complete and accurate medical record for each pt?
·  Are the components of the medical record defined?
·  Is unique patient information contained in the medical record used for patient identification?
·  Does the information in the medical record support the patient’s diagnosis and condition?
·  Does the information in the medical record validate the patient’s care, treatment and services?
·  Does the information in the medical record document the course and result of the patient’s care, treatment and services?
·  Does the information in the medical record promote continuity of patient care?
·  Are standardized formats used in the medical record?
·  Are dates included on all entries?
·  Does the hospital track all components of the medical record?
·  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? (MM.01.01.01, EP 1)
·  Are all entries in the medical record (including orders) timed?
RC.01.02.01 – Does staff authenticate all entries in the medical record?
·  Does only authorized staff make entries in the medical record?
·  Are the types of entries made by non-independent practitioners that need countersignatures defined?
·  Is the author identified for all entries identified in the medical record?
·  Does the author authenticate information entered into the medical record including transcription or dictation?
·  Is the person who uses a signature stamp or electronic authentication the only one who uses it? NOTE – CMS forbids use of a signature stamp.
RC.01.03.02 – Is documentation timely?
·  Is there a policy that requires timely entries?
·  Is the time frame for record completion defined?
·  Does the time frame exceed 30 days after discharge?
·  Is the timely entry policy implemented? (PC.01.02.03, EP 2)
·  Are H&Ps, including updates, recorded within 24 hours after registration or inpatient admission?
·  Are H&Ps recorded prior to surgery or a procedure requiring anesthesia?
RC.01.04.01 – Does the organization conduct medical record audits?
·  Does the hospital conduct ongoing reviews of medical records at the point of care based on presence, timeliness, legibility, accuracy, authentication and completeness? (MS.05.01.03, EP3)
·  Does staff measure medical record delinquency rates regularly but no less than every three months?
·  Does the medical record delinquency rate averaged from the last quarterly measurements equip 50% or less of the average monthly discharge rate? Are individual quarterly measurements no greater than 505 of the average monthly discharge rate?
RC.01.05.01 – Does the hospital retain its medical record?
·  Is the retention time of the original or legally reproduced medical record defined in policy and based on use, law and regulation?
·  Are records released based only when responding to law and regulation?
RC.02.01.01 – Does the medical record contain information that reflects patient care, treatment and services?
·  Is the following information included in the medical record?
-  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 language and communication needs?
·  Is the following clinical information included in the medical record?
-  Admission reason?
-  Initial diagnosis, diagnostic impressions or conditions?
-  Results of assessments and reassessments? (PC.01.02.01, EPs 1 & 4, PC.03.01.03, EPs 1 & 8)
-  Food allergies?
-  Medication allergies?
-  H&P examination, conclusions or impressions?
-  Diagnosis or condition?
-  Consultative reports?
-  Observations?
-  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.01.03.01, EPs 1 & 23)
-  Results of diagnostic and therapeutic tests and procedures?
-  Medications dispensed or prescribed at discharge?
-  Discharge diagnosis?
-  Discharge plan and planning evaluation?
·  Is the following additional information included in the medical record as needed for care, treatment, and services?
-  Advance directives? (RI.01.05.01, EP 11)
-  Informed consent as required by hospital policy? (RI.01.03.01, EP 13)
-  Communication with the patient, such as telephone calls or e-mail?
-  Patient-generated information?
·  Is the following information included in the medical record of a patient receiving urgent or immediate care?
-  Time and means of arrival?
-  If applicable, indication that the patient left against medical advice?
-  Conclusions arrived at once care, treatment, and services ended, including final disposition, conditions, and instructions for follow-up care?
-  A copy of information is made available to practitioners or organizations providing follow-up care?
RC.02.01.03 – Does the medical record document operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia?
·  Does staff document operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia?
·  Does a LIP involved in the patient’s care document the provisional diagnosis before the patient undergoes an operative or other high-risk procedure?
·  Is the medical history and physical examination recorded in the medical record before the patient undergoes an operative or other high-risk procedure? ({PC.01.02.01, EPs 4 & 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?
·  Is the following information included in the operative or other high-risk report?
-  Name of the LIP who performed the procedure and name of any assistants?
-  Name, description, and findings of the procedure?
-  Estimated blood loss?
-  Specimens removed, if any?
-  Postoperative diagnosis?
·  Is a progress note entered in the medical record before the patient is transferred to the next level of care?
·  Does the progress note include the following?
-  Name of the LIP who performed the procedure and name of any assistants?
-  Name, description, and findings of the procedure?
-  Estimated blood loss?
-  Specimens removed, if any?
-  Postoperative diagnosis?
·  Is the following postoperative information included in the medical record? (PC.03.01.05, EP 1, PC.03.01.07, EP 1)
-  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?
·  Does the medical record document that a 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.03.01.07, EP 4)
·  Does the medical record document that staff used approved discharge criteria to determine the patient’s readiness for discharge? (PC.03.01.07, EP 4)
·  Does the postoperative documentation include the name of the LIP responsible for discharge?
RC.02.01.05 – Does the medical record document the use of restraint and/o seclusion?
·  Does staff document the following information involving the use of restraint/seclusion for non-behavioral health reasons?
-  Orders for use?
-  Results of patient monitoring?
-  Reassessments?
-  Unanticipated changed in the patient’s conditions? (PC.03.02.07, EPs 1 & 2)
·  Are all instances of the use of restraint protocols for non-behavioral health reasons documented in the medical record? (PC.03.02.05, EP 1)
·  Is the following information regarding the use of restraint/seclusion for behavioral health reasons included in the medical record?
-  Each episode of restraint/seclusion?
-  Circumstances that led to the use of restraint/seclusion?
-  Consideration or failure of nonphysical alternatives?
-  Rationale for the use of the type of physical intervention?
-  Written orders? (PC.03.03.13, EPs 1-3)
-  Each verbal order received from the LIP? (PC.03.03.17, EP 1)
-  Each in-person evaluation and reevaluation?
-  Each 15-minute assessment of the patient’s status? (PC.03.03.07, EP 5)_
-  Continuous monitoring of the patient? (PC.03.03.25, EPs 1 & 2)
-  Any preexisting medical conditions or physical disability that would place the patient at greater risk during an episode of restraint/seclusion?