Here Comes The Joint Commission

by Dr. Judith Bodnar, medical staff president

Anytime after the first week of January, we are in line for our reaccreditation visit from The Joint Commission (TJC). Recently, we performed a “mock” survey and fell short in several areas. One area we fell particularly short in is documentation issues. We need your help!

Signing, dating and timing of all chart entries, meaning progress notes, orders, post-op notes and consents: This is a requirement for meeting Conditions of Participation (CoP) for our continued ability to care for Medicare and Medicaid (CMS) patients and a part of TMCA’s Medical Staff Rules and Regulations.

Unapproved Abbreviations: Our Rules and Regs and TJC state that the following abbreviations are not approved: U, IU, QD, QOD, trailing zero, lack of leading zero, MS, MSO4 and MgSO4. There is evidence that use of those abbreviations can lead to confusion and medical errors. Examples of proper use: Use daily or Q day, 0.25 mg, every other day.

Histories and Physicals: TJC, CMS (CoP) and the Medical Staff Rules and Regs state the following: If a Practitioner has obtained a complete history or has performed a complete physical examination within thirty (30) days prior to the patient’s admission to the hospital, then a durable, legible, copy of the report may be used in the patient’s hospital medical record in lieu of the admission history and physical. However, H&Ps completed prior to admission, but less than 30 days may be used provided an interval note recording updates to the patient’s condition is documented on admission on or attached to the history and physical or the admission progress report. The interval note should include whether or not there are changes, content of changes if applicable and the date and signature of the physician. History and physicals greater than 30 days prior to admission will not suffice.

Prior to an invasive procedure an updated note must be documented acknowledging your review of the H & P noting an examination for any changes in the patient's condition since the time that the patient's H&P was performed. Changes that might be significant for the planned course of treatment are of particular importance.

Consents: The consent forms must be legible, using lay language to describe the procedure, dated and timed, and signed by the patient or responsible persons.

Pain Management: When ordering medication for pain control with an as needed (prn) order, we must denote the pain levels for which multiple medications might be used by the nurses. For example: using the pain level as determined from a pain scale, you might be using Tylenol prn a pain scale <4 and dilaudid for pain rated at > 6.

Post-Procedure notes: Post-procedure notes must be completed prior to moving the patient to the next level of care (PACU or ICU) and should include the required components as outlined in the Medical Staff Rules and Regulations, and as required by CMS (CoP) and TJC. You may enter the required information in the progress note, or, better yet, use the available pre-printed forms.