Record of Care, Treatment and Services Stephanie Allen Accreditation and Regulatory Manager

1. Record of Care, Treatment and ServicesStephanie AllenAccreditation and Regulatory Manager

2. Goals • Describe the importance of the record of care • Understand medical record documentation requirements for Joint Commission and CMS • Identify most hot topics for compliance

3. Why is it Important? • Contains all the data and information gathered about a patient from entry to discharge/transfer • Historical record the a patient’s episode of care • This is the only evidence that quality care was provided!

4. Why is it Important? • A key source used to determine compliance • Method of communication between practitioners and staff • Information must be organized, standardized and understandable • Everyone involved with patient care and support of care must know how to use it • Payment

5. The Acronyms • TJC: The Joint Commission • RC: Record of Care (TJC chapter) • EP: Element of Performance • CMS: Centers for Medicare & Medicaid Services • CoPs: Conditions of Participation (the regulatory “chapters” for CMS)

6. TJC RC Chapter The Chapter Outline • Plan • Clinical Record Components • Authentication • Timeliness • Audit • Retention • Implement • Care, Treatment, and Services • Verbal Orders • Discharge Information

7. TJC RC ChapterClinical Record Components • Outlines required documentation for • Screenings, Assessments, Reassessments • Pre- and postoperative procedures • Moderate or deep sedation or anesthesia • Discharge

8. RC.01.01.01 Complete and Accurate Medical Record EP 9: Standardized formats to document care EP 11: All entries in the medical record are dated EP 12: Tracks the location of all components of the medical record EP 19: For Deemed status: All entries in the medical record, including all orders, are timed 61% non-compliance in 2012 surveys

9. RC.01.02.01Authentication EP 3: Author of each medical record entry is identified in the medical record EP 4: Entries in the medical record are authenticated by the author. Information introduced into the medical record through transcription or dictation is authenticated by the author. Who? Who?

10. RC.01.04.01Audits EP 1: Conduct ongoing review of medical records at the point of care. Indicators: • Presence • Timeliness • Legibility • Accuracy • Authentication • Completeness of data and information EP 3: Measure the medical record delinquency rate at regular intervals, but no less than every three months www.jointcommission.org/Hospital_Medical_Record_Statistics_Form/

11. RC.02.01.03High-Risk procedures and the use of Moderate/Deep Sedation/Anesthesia EP 2: LIP involved in patient’s care documents the provisional diagnosis before the procedure is performed. EP 3: History and Physical examination is recorded before the procedure EP 5-7: Post procedure/ post operative note is completed before the patient is transferred to the next level of care. Seven (7) required elements

12. RC.02.04.01Discharge Information EP 1: Discharge Summary must include: • Reason for hospitalization • Procedures performed • Care, treatment, services provided • Patient’s condition and disposition at discharge • Information provided to patient and family • Provisions for follow-up care How do you know you are compliant?

13. And then we have CMS….

14. CoP: Medical Record Services§482.24 • A medical record must be maintained for every individual evaluated or treated in the hospital • Inpatient and Outpatient • Sample Review: 10% of the ADC and no less than 30 records

15. CoP: Medical Record Services§482.24 • Contents – Accurately Written • All Orders • Test Results • Evaluations • Care Plans • Treatments • Interventions • Care Provided • Patient’s response

16. CoP: Medical Record Services§482.24 • Promptly Completed • Completed “promptly” after discharge in accordance with State law and hospital policy • But no later than 30 days after discharge • Properly filed and retained • Prompt retrieval of any medical record within last 5 years • Security • Accessible

17. CoP: Medical Record Services§482.24 • Other Requirements • System for author identification • How do you identify the author of each entry? • Remember RC.01.02.01 • Protect the security of all record entries

18. CoP: Content of Record§482.24(c) • Must contain information to • Justify admission • Justify continued hospitalization • Support diagnosis • Describe patient's progress • Describe patient’s response to medications • Describe patient's progress and response to services ex: interventions, care, treatments

19. CoP: Content of Record§482.24(c) • Medical record entries • Legible: Orders, progress notes, nursing notes or other entries in the medical record

20. CoP: Content of Record§482.24(c) • Medical record entries • Legible • Complete • Sufficient information to identify the patient • Support diagnosis/condition • Justify care, treatment, services • Promote continuity of care among providers

21. CoP: Content of Record§482.24(c) • Medical record entries • Legible • Complete • Dated, timed and authenticated • Authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures

22. CoP: Dating and Timing§482.24(c) • Preprinted Order Sets • Sign, date, time last page of the orders, with the last page also identifying the total # of pages in the order set • Sign or initial any other pages of the order set where selections or changes have been made

23. CoP: History and Physicals§482.24(c) • Update to H&P (that meets previous slide requirements) must be documented within 24 hours after admission or registration • But PRIOR to surgery or a procedure requiring anesthesia services

24. CoP: History and Physicals§482.24(c) • No more than 30 days before or 24 hours after admission or registration • But PRIOR to surgery or a procedure requiring anesthesia services • Who can complete H&Ps in your facility?

25. Hot Topics • Stamps • Legibility • Electronically-generated documents • Ex: EKG printouts, lab results • Late entries • What is your policy?

26. Hot Topics • Scribes – unlicensed individuals • Training & competency • Job description & performance evals • All entries must be signed by scribe – title, date and time • LIP or practitioner must authenticate all entries by signing, dating and timing • Scribes should NOT be entering orders into the medical records

27. Questions?