APPENDIX 8A: MEDICAL RECORD SERVICES

APPENDIX 8A: MEDICAL RECORD SERVICES

Source: Accreditation Manual for Hospitals (1992, pp. 49-54). Copyright Joint Commission on Accreditation of Healthcare Organizations.

MR.1 The hospital maintains medical records that are documented accurately and in a timely manner, are readily accessible, and permit prompt retrieval of information, including statistical data.

MR.1.1 An adequate medical record is maintained for each individual who is evaluated or treated as an inpatient, ambulatory care patient, or emergency patient.

MR.1.2 All significant clinical information pertaining to a patient is incorporated in the patient's medical record.

MR.1.3 The content of the medical record is sufficiently detailed and organized to enable

MR.1.3.1 the practitioner responsible for the patient to provide continuing care to the patient, determine later what the patient's condition was at a specific time, and review the diagnostic and therapeutic procedures performed and the patient's response to treatment;

MR.1.3.2 a consultant to render an opinion after an examination of the patient and a review of the medical record;

MR.1.3.3 another practitioner to assume the care of the patient at any time; and

MR.1.3.4 the retrieval of pertinent information required for utilization review and quality assessment and improvement activities.

MR.1.4 A system is established by the organization to routinely assemble all divergently located record components when a patient is admitted to the hospital or appears for a prescheduled ambulatory care appointment.

MR.2 The medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and results accurately.

MR.2.1 Although the format and forms in use in the medical record will vary, all medical records contain the following:

MR.2.1.1 identification data;

MR.2.1.2 the medical history of the patient;

MR.2.1.3 as appropriate to the age of the patient, a summary of the patient's psychosocial needs;

MR.2.1.4 reports of relevant physical examinations;

MR.2.1.5 diagnostic and therapeutic orders;

MR.2.1.6 evidence of appropriate informed consent;

MR.2.1.6.1 A policy on informed consent is developed by the medical staff and governing body and is consistent with any legal requirements.

MR.2.1.6.2 The medical record contains evidence of informed consent for procedures and treatments for which it is required by the policy on informed consent.

MR.2.1.7 clinical observations, including the results of therapy;

MR.2.1.8 reports of procedures, tests, and their results; and

MR.2.1.9 conclusions at termination of hospitalization or evaluation/treatment.

MR.2.2 Inpatient medical records also include at least the following:

MR.2.2.1 the patient's name, address, date of birth, and next of kin;

MR.2.2.2 the medical history of the patient including the following information:

MR.2.2.2.1 the chief complaint;

MR.2.2.2.2 details of the present illness, including, when appropriate, assessment of the patient's emotional, behavioral, and social status;

MR.2.2.2.3 relevant past, social, and family histories appropriate to the age of the patient; and

MR.2.2.2.4 an inventory by body systems;

MR.2.2.3 in regard to services for children and adolescents,

MR.2.2.3.1 an evaluation of the patient's developmental age;

MR.2.2.3.2 consideration of educational needs and daily activities, as appropriate;

MR.2.2.3.3 the parent's report or other documentation of the patient's immunization status; and

MR.2.2.3.4 the family's and/or guardian's expectations for, and involvement in, the assessment, treatment, and continuous care of the patient;

MR.2.2.4 the medical history, which is completed within the first 24 hours of admission to inpatient services;

MR.2.2.5 the report of the physical examination;

MR.2.2.5.1 The report reflects a comprehensive current physical assessment.

MR.2.2.5.2 The physical assessment is completed within the first 24 hours of admission to inpatient services.

MR.2.2.5.2.1 If a complete physical examination has been performed within 30 days prior to admission, such as in the office of a physician staff member or, when appropriate, the office of a qualified oral-maxillofacial surgeon staff member, ... a durable, legible copy of this report may be used in the patient's hospital medical record, provided there have been no changes subsequent to the original examination or the changes have been recorded at the time of admission.

MR.2.2.5.3 The recorded physical examination is authenticated by a physician or, when appropriate, by a qualified oral-maxillofacial surgeon member of the medical staff.

MR.2.2.6 a statement of the conclusions or impressions drawn from the admission history and physical examination;

MR.2.2.7 a statement of the course of action planned for the patient while in the hospital;

MR.2.2.7.1 There is a periodic review of the planned course of action, as appropriate.

MR.2.2.8 diagnostic and therapeutic orders;

MR.2.2.8.1 Verbal orders of authorized individuals are accepted and transcribed by qualified personnel who are identified by title or category in the medical staff rules and regulations.

MR.2.2.8.2 The medical staff defines any category of diagnostic or therapeutic verbal orders associated with any potential hazard to the patient.

MR.2.2.8.2.1 Such orders are authenticated within 24 hours by the practitioner responsible for the patient.

MR.2.2.9 progress notes made by the medical staff and other authorized individuals;

MR.2.2.10 consultation reports;

MR.2.2.11 nursing notes and entries by nonphysicians that contain pertinent, meaningful observations and information;

MR.2.2.12 reports of procedures, tests, and their results;

MR.2.2.12.1 All diagnostic and therapeutic procedures are recorded and authenticated in the medical record.

MR.2.2.12.2 When there is a transcription and/or filing delay, a comprehensive operative progress note is entered in the medical record immediately after surgery to provide pertinent information for use by any individual who is required to attend to the patient.

MR.2.2.13 reports of pathology and clinical laboratory examinations, radiology and nuclear medicine examinations or treatment, anesthesia records, and any other diagnostic or therapeutic procedures; and

MR.2.2.14 conclusions at termination of hospitalization.

MR.2.2.14.1 All relevant diagnoses established by the time of discharge, as well as all operative procedures performed, are recorded, using acceptable disease and operative terminology that includes topography and etiology, as appropriate.

MR.2.2.14.2 The clinical resume concisely recapitulates the reason for hospitalization, the significant findings, the procedures performed and treatment rendered, the condition of the patient on discharge, and any specific instructions given to the patient and/or family, as pertinent.

MR.2.2.14.2.1 Consideration is given to instructions relating to physical activity, medication, diet, and follow-up care.

MR.2.2.14.3 A final progress note may be substituted for the resume in the case of patients with problems of a minor nature who require less than a 48-hour period of hospitalization, and in the case of normal newborn infants and uncomplicated obstetric deliveries.

MR.2.2.14.3.1 The final progress note includes any instructions given to the patient and/or family.

MR.2.2.14.4 When an autopsy is performed, provisional anatomic diagnoses are recorded in the medical record within three days, and the complete protocol is made part of the record within 60 days, unless exceptions for special studies are established by the medical staff.

MR.3 Medical records are confidential, secure, current, authenticated, legible, and complete.

MR.3.1 The hospital is responsible for safeguarding both the record and its informational content against loss, defacement, and tampering and from use by unauthorized individuals.

MR.3.2 Written consent of the patient or the patient's legally qualified representative is required for the release of medical information to persons not otherwise authorized to receive the information.

MR.3.2.1 There is a written hospital and medical staff policy that medical records may be removed from the hospital's jurisdiction and safekeeping only in accordance with a court order, subpoena, or statute.

MR.3.3 When certain portions of the medical record are so confidential that extraordinary means are necessary to preserve their privacy, such as in the treatment of some psychiatric disorders, these portions may be stored separately, provided the complete record is readily available when required for current medical care or follow-up, review functions, or use in quality assessment and improvement activities.

MR.3.3.1 The medical record indicates that a portion has been filed elsewhere, in order to alert authorized reviewing personnel of its existence.

MR.3.4 The quality of the medical record depends in part on the timeliness, meaningfulness, authentication, and legibility of the informational content.

MR.3.4.1 Entries in medical records are made only by individuals given this right as specified in hospital and medical staff policies.

MR.3.4.2 All entries in the record are dated and authenticated, and a method is established to identify the authors of entries.

MR.3.4.2.1 Identification may include written signatures, initials, or computer key.

MR.3.4.2.2 When rubber-stamp signatures are authorized, the individual whose signature the stamp represents places in the administrative offices of the hospital a signed statement to the effect that he/she is the only one who has the stamp and is the only one who will use it.

MR.3.4.2.2.1 There is no delegation of the use of such a stamp to another individual.

MR.3.4.3 The parts of the medical record that are the responsibility of the medical practitioner are authenticated by the practitioner.

MR.3.4.4 When members of the house staff are involved in patient care, sufficient evidence is documented in the medical record to substantiate the active participation in, and supervision of, the patient's care by the attending physician responsible for the patient.

MR.3.4.5 Any entries in the medical record by house staff or nonphysicians that require countersigning by supervisory or attending medical staff members are defined in the medical staff rules and regulations.

MR.3.5 Each clinical event is documented as soon as possible after its occurrence.

MR.3.6 The records of discharged patients are completed within a period of time that in no event exceeds 30 days following discharge.

MR.3.6.1 The period of time is specified in the medical staff rules and regulations.

MR.3.6.2 A medical record is ordinarily considered complete when the required contents, including any required clinical resume or final progress note, are assembled and authenticated, and when all final diagnoses and any complications are recorded, without use of symbols or abbreviations.

MR.4 The medical record department is provided with adequate direction, staffing, and facilities to perform all required functions.

MR.4.1 Medical record services are directed by a qualified medical record administrator or technician who possesses the administrative skills necessary to provide effective leadership and management of medical record information systems.

MR.4.1.1 When employment of a registered or accredited individual is impossible, the hospital secures the consultative assistance of a qualified registered record administrator or accredited record technician.

MR.4.2 The length of time that medical records are to be retained is dependent on the need for their use in continuing patient care and for legal, research, or educational purposes and on law and regulation.

MR.4.3 Whatever filing and storage system is used, it provides for easy retrievability of records.

MR.4.3.1 Retrievability of pertinent information is assured by the use of an acceptable coding system for disease and operation classifications, and by the use of an indexing system to facilitate the acquisition of medical statistical information.

MR.4.3.2 Verification checks for accuracy, consistency, and uniformity of data recorded and coded for indexes, statistical record systems, and use in quality assessment and improvement activities are a regular part of the medical record abstracting process.

MR.5 The role of medical record personnel in the hospital's overall program for the assessment and improvement of quality and in committee functions is defined.

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APPENDIX 8A: MEDICAL RECORD SERVICES