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ASSESSMENT OF MEDICAL DOCUMENTATION AS PER JOINT COMMISSION INTERNATIONAL

R. K. Sinha*, D. Saha**, Prathibha N. R.***

Keywords : Assessment, Medical Records, Joint Commission International. INTRODUCTION Medical record is a systematic documentation of a patient's personal and social data, history of his or her ailment, clinical findings, investigations, diagnosis, treatment given, and an account of follow-up and final outcome.(1) The quality of a patient record depends largely on the individuals making record entries. All healthcare practitioners and others who enter information into patient records must understand the importance of creating complete and accurate records, as well as the legal and medical implications of failing to do so. A medical record enables healthcare professionals to plan and evaluate a patient's treatment and ensures continuity of care among multiple providers. The quality of care a patient receives depends directly on the accuracy and legibility of the information the medical record contains.(2) Maintaining a complete record is important not only to comply with licensing and accreditation requirements, but also to enable a healthcare provider to establish that a patient received adequate care. Statutes, accreditation standards, and professional associations frequently impose standards relating to the legibility, accuracy, and completeness of medical records.(3) Joint Commission on Accreditation of Healthcare Organization's (Joint Commission International) standards of accreditation for hospitals, require that data be collected in a timely, economic, and efficient manner using the degree of accuracy and completeness necessary for the data's required use.(4) Joint Commission standards require health records to be periodically reviewed for completeness, accuracy, and timeliness of the information they contain.(5)

ABSTRACT

Objective : To evaluate the medical documentation process compared to criterion as per Joint Commission International. Method : A retrospective study was conducted in a cancer hospital of Karnataka, India, for a period of 4 months. A total of 600 discharged inpatient records were randomly selected from the records of total patients admitted and discharged during the year 2008. A checklist was then prepared as per the medical documentation criterion laid down by JCI. To measure the compliance three options were included i.e. "Yes", "No" and "Not Applicable". The forms considered for the assessment were Admission form, Consent form, Radiation form, Brachytherapy form, Anesthesia consent and management form, Post operative form, Doctor's record, Nurses record and Discharge Summary. Results : A total of 49% non compliance was seen in General consent in respect to the signature of doctors with date, whereas, 18% of anesthesia forms failed to provide any evidence of anesthesia used during the surgery. It was found that the standard documentation of the discharge summary was most dissatisfactory, where 44% of discharge summary does not comply with criteria of JCI. Conclusion : Though overall medical documentation process was satisfactory, the documentation of General consent form and Anesthesia form needs to be enhanced further as per the standards framed by the Joint Commission International. Special attention should be given to the complete and accurate documentation of Discharge summary.

*

Associate Professor, Department of Health Information Management, Manipal College of Allied health Sciences, Manipal University, Manipal - 576 104, Karnataka, India. ** Lecturer, Department of Health Information Management, Manipal College of Allied Health Sciences, Manipal University. Manipal - 576 104, Karnataka, India. *** Post Graduate Student, Masters of Hospital and Health Information Administration, Department of Health Information Management, Manipal College of Allied Health Sciences, Manipal University, Manipal - 576 104, Karnataka, India.

Journal of the Academy of Hospital Administration, Volume 21, No. 1 & 2 Jan-June & July-December 2009

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Original Article

A healthcare facility's bylaws or policies should require medical staff members to complete patient records within the specified time, and should provide an automatic suspension of clinical privileges for those who fail to comply. Usually, the medical records department or health information manager has the responsibility for making sure that records are completed within a specific time. Therefore, this department or manager should establish procedures for notifying attending physicians when records are incomplete. It is the responsibility of a healthcare facility, therefore, to establish policies that require each practitioner to function within the scope of his or her practice as authorized by state licensing or state certification statutes, or, in the absence of such statutes, as defined by his or her professional competence.(6,7) METHODS A retrospective study was conducted for a period of 5 months in a cancer hospital of Karnataka. A total of 600 medical records were randomly selected from the total 12000 medical records of the patients who visited during the year 2008 using the simple random sampling method. Medical records of the expired patients were not included in the study. The records were reviewed for the completeness and accuracy using checklist based on JCI medical documentation standard. The criteria employed are "Yes", "No" and "Not applicable (NA)" as the options. The data was collected by analyzing the filing and assembling system, coding of the record during the review period, Admission forms, General consent form, Special consent form, Radiation form, Brachytherapy

forms, Anesthesia consent form, Anesthesia management form, Post-operative record, Doctor's report, Nurse's record, and Discharge Summary. The entries in the form were assessed based on the standards in the checklist. Collected data were analyzed using SPSS 11.5 and percentages were drawn. RESULTS AND DISCUSSION According to the estimated sample size, a total of 600 medical records were reviewed. Firstly the records were categorized based on the type of the treatment rendered to the patient. Among that, 25.5% (153) were found to have received chemotherapy, 28.8% (173) Brachytherapy, 26.7% (160) Radiation therapy and 19.0% (114) underwent surgery (Table-2). Based on this finding the commonly used forms were identified and a checklist was drawn. The checklist had 12 headings and subheadings based on the forms used in the hospital. This checklist allowed for comparison of all commonly used forms against the JCI medical documentation standards. Based on the findings the results are discussed hereunder: Filing, Assembling and Coding of records Of the total 600 medical records reviewed and compared with JCI requirements, all records were found to be properly filed. A total of 97% medical records were found to be compliant with the standards in term of assembling of medical records and disease coding as per International Classification of Diseases - Oncology - 3rd version (ICD-O-3). Improper assembling of records contributed to the 3% deficiency. (See Table 2 - Section. 1 & 2)

Table­1 : Categorization of medical records as per the treatment rendered to the patient Sl. No. 1. 2. 3. 4. Type of Treatment Given (n = 600) Surgery Radiation Therapy (RT) Brachytherapy (BT) Chemotherapy (CT) Percentage (%) 19.2% 26.7% 28.8% 25.3%

n = total number of records

Journal of the Academy of Hospital Administration, Volume 21, No. 1 & 2 Jan-June & July-December 2009

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Original Article

Table­2 : Review of Medical Record forms as per JCI medical documentation criteria. Sl. No. Medical Records Forms & Components Assessed Total Number of Records (600) Yes 1 2 3 3.1 3.2 3.3 3.4 3.5 4 4.1 4.1.1 4.1.2 4.1.3 4.1.4 4.2 4.2.1 4.2.2 4.2.3 4.2.4 4.2.5 5 5.1 5.2 5.3 5.4 6. 6.1 6.2 6.3 Filing of records Assembling and Coding of the record Admission forms (n - 600) Patient details entered Reporting Signature of the doctor Corporate/TPA patient marked Admission consent form Consent forms General consent form (n = 600) Patient name with procedure Signature of the patient with date Signature of the doctor with date Signature of the witness Special Consent (n = 317) Patient profile (IP no, Name, Bed no) Name and signature of the patient Signature of the witness with date Signature of the performing doctor with date Indication of surgery/procedure Radiation forms (n = 160) Patient profile Signature of the patient Treatment plan written properly Signature of the physicist/doctor Brachytherapy forms (n = 173) Patient profile documented Treatment plan written properly Description of procedure, doctor signature and date 173 173 173 100 100 100 0 0 0 0 0 0 427 427 427 71.2 71.2 71.2

7

% 100 97.0

No 0 18

% 0 3.0

NA 0 0

% 0 0

600 582

600 600 600 600 574

100 100 100 100 95.7

0 0 0 0 26

0 0 0 0 4.3

0 0 0 0 0

0 0 0 0 0

600 600 308 600

100 100 51.3 100

0 0 292 0

0 0 48.7 0

0 0 0 0

0 0 0 0

317 296 317 317 317

100 93.4 100 100 100

0 21 0 0 0

0 6.6 0 0 0

283 283 283 283 283

47.2 47.2 47.2 47.2 47.2

160 160 160 160

100 100 100 100

0 0 0 0

0 0 0 0

440 440 440 440

73.3 73.3 73.3 73.3

Journal of the Academy of Hospital Administration, Volume 21, No. 1 & 2 Jan-June & July-December 2009

Original Article

Table­2 (contd.) Sl. No. Medical Records Forms & Components Assessed Total Number of Records (600) Yes 7. 7.1 7.2 8. 8.1 8.2 8.3 8.4 8.5 9. 9.1 9.2 9.3 9.4 9.5 10 10.1 10.2 11 11.1 11.2 12 12.1 12.2 12.3 12.4 12.5 12.6 Anesthesia Consent forms (n = 114) Anesthetist, name, signature and date Signature of the patient Anesthesia Management Form (n - 114) Patient profile documented Signature of the doctor with name and date Pre anesthetic assessment Anesthesia used documented Physiological changes of the patient Postoperative forms (n = 114) Post surgery psychological status Post surgical medical description Patient care planned and documented after surgery Signature and date by the doctor 114 114 114 114 100 100 100 100 100 0 0 0 0 0 0 0 0 0 0 486 486 486 486 486 81 81 81 81 81 114 114 114 93 107 100 100 100 81.5 93.8 0 0 0 21 7 0 0 0 18.4 6.1 486 486 486 486 486 81 81 81 81 81 114 114 100 100 0 0 0 0 486 486 81 81 % No % NA %

Pre operative diagnosis tallies with the post operative 114 Doctor's record (n = 600) Date, time and Signature Making entries daily Nurse's record (n = 600) making daily entries Date, time and signature Discharge summary (n = 600) Chief complaint, past history, physical examination Medication and Treatment given Condition at discharge Date or time for next follow up 335 335 335 335 600 600 600 600

100 100

0 0

0 0

0 0

0 0

100 100

0 0

0 0

0 0

0 0

55.8 55.8 55.8 55.8 55.8 55.8

265 265 265 265 265 265

44.2 44.2 44.2 44.2 44.2 44.2

0 0 0 0 0 0

0 0 0 0 0 0

Discharge medication or any advice on the discharge 335 Signature of the doctor 335.

n = Total Number of Medical Record Forms Assessed for Each Component

Journal of the Academy of Hospital Administration, Volume 21, No. 1 & 2 Jan-June & July-December 2009

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Original Article

Review of Medical Records (n=600) Data was collected by reviewing of the discharged inpatients medical records using the checklist as per the JCI documentation standards. Entries of the admission form such as patient's details, date of admission, name of the doctor, doctor's signature, TPA indication, were found to be 100% compliant with the standards, whereas only 95.7% (574) of admission consent forms met the standards in terms of name, signature, and relation of the patient relative in the admission consent (See Table 2- Section. 3) General consent forms are only taken during certain procedures like X-ray, CT scan, MRI scan etc. The entries made in general consent forms were found to be compliant with the standards where 100% satisfaction had been observed in terms of mentioning the patient name with procedure, in having signature of the patient and the signature of witness. A huge 48.7% non conformity was seen in terms of signature of the doctor with date. This issue needs to be taken care of to avoid any legal implications in future. (See Table 2 - Section. 4.1) In cancer care, special consent forms are used for recording treatments such as surgery, Direct laryangoscopy, Palliative treatment, Brachytherapy, radiation therapy. Out of 600 patient records, 317 records were found to have special consent form for the above treatment procedures. Out of the 317 records, in 21 special consent forms were found to be without patient signature which can have legal implications and should be a regular practice to check (See Table - 3, Section. 4.2) Out of 600 medical records, 160 records were found to have radiation therapy forms and 173 records with Brachytherapy forms. The documentation of Radiation and Brachytherapy forms were 100% compliant with the criteria mentioned under the JCI standards. (See Table -3, Section.5 & 6) Out of 600, 114 medical records were found to have anesthesia consent forms and all the entries in it were found to be 100% compliant with the standards. (See Table -3, Section.7) The entries of Anesthesia management forms were found to be adquate except for the very crucial entry about the anesthesia used, where 18.4% (21) of the records did not have documentation regarding it.

Anesthesiologist should take care in documenting the anesthesia used as in case of complications or even in case of legal litigations, it will be important piece of evidence. It should be brought to the notice of the defaulting doctors and further care should be taken regarding documenting the appropriate anesthesia administered during surgery. (See Table -3, Section.8) It was also observed that 6.1% records failed to document the physiological changes of the patient during the administration of anesthesia in the form. (See Table -3, Section.8) This also needs to be looked into and measures taken to avoid such omissions in future. Postoperative forms, doctor's order and nurse's records were found to be 100% compliant with the standard criteria mentioned under checklist. (See Table -3, Section.9, 10 & 11) Out of 600 medical records, only 335 were found to have discharge summary in them. The rest 265 records did not have discharge summary in them. All 335 discharge summaries present were 100% compliant with the laid down JCI standards. But, care should be taken to complete and document the discharge summaries for all the in- patient records of the hospital. This is a major non-compliance and efforts should be taken by the hospital to look into the reasons for incomplete/no discharge summaries in the records. (See Table -3, Section.12) RECOMMENDATIONS Based on the findings of the study, following recommendations were made · Doctor's should sign in the general consent forms as it shows permission by the patient to the procedure. Care should be taken to see that all general consent forms have signature of the doctor and the patient. Having signature of the concerned staff in the record is one of the standard criteria set by JCI. Care should be taken to type and document the discharge summaries in each and every record as the documentation of the discharge summary is compulsory for continuity of care. The Medical Record department/personnel should identify incomplete records and send them to the concerned professional to complete and then only

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Journal of the Academy of Hospital Administration, Volume 21, No. 1 & 2 Jan-June & July-December 2009

Original Article

it should be filed. · Additionally, the nursing station staff may also take up the responsibility of ensuring that all the details of the patient in forms / records are complete, while they are in charge of that patient, so that if any variations are found they can solved immediately. This will help minimize the movement of incomplete forms / records. In order to make the staff of the hospital (doctors, nurses, social workers etc) aware about the documentation standards, medical record personnel should circulate standard guidelines list to every department. To have a periodic weekly auditing to minimize chances of deficiency/misplacing. Periodic training sessions and workshops should be organized by management in order to educate the staff about the importance of the documentation and update them on the latest in documentation methodologies/technologies. The medical record department/personnel should take the responsibility of organizing such events.

·

the records, like not having the signature in General consent form and Preoperative form, no documentation of anesthesia used in some of the anesthesia form and absence of/incomplete discharge summaries. This needs to be carefully monitored and doctors made aware of their responsibility to completely fill each entries in these forms, which not only form the basis of documentation of care given and aids in the continuity of care, but also is an important document in case of any legal litigations. Regular medical record audits and an ongoing training to all the members of the healthcare team could go a long way in ensuring complete and proper documentation of patient medical records. REFERENCES 1. B M Sakharkar. Principles of Hospital Administration and Planning. 1st edition 1998: 225. 2. William H. Roach, Robert G. Hoban, Bernadette M.Broccole, Andrew B. Roth, Timothy P. Blanchard. Medical Records and the Law. American Health Information Management Association, Jones and Bartlett Publishers, 4th Edition, 51-69. 3. Practice Brief: Best Practices in Medical Record Documentation and Completion (1999), available from URL.http://library.ahima.org/xpedio/groups/ public/documents/ahima/pub_bok_000043.html. 4. Comprehensive Accreditation Manual for Hospitals, Standard IM.3.10. Joint Commission on Accreditation of Healthcare Organizations, 2005 5. Comprehensive Accreditation Manual for Health Care Networks, Standard IM.3.2.1. Joint Commission, 2003-2004. 6. Comprehensive Accreditation Manual for Hospitals, Standard IM.6.10.-6.60 Joint Commission, 2005. 7. Comprehensive Accreditation Manual for Home Care, Standard IM.6.10.1. Joint Commission, 20042005.

· ·

CONCLUSION Hospital accreditation and licensing of the healthcare services is only possible when the hospital assures and provides excellent services to the patient. This can only be achieved through the medical records of the patient maintained in the hospital. The completeness and accuracy of the information is the important criteria a hospital has to fulfill to get accredited with JCI. The study at the hospital showed that there was compliance in the Admission form, Special consent form, History and Physical examination form, Radiation form, Brachytherapy form, Anesthesia consent form, Post operative form, Laboratory form, Doctor's record and Nurses record having almost met the standards criteria set by the JCI. There was deficiency noted in

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