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Topic: Brush up on documentation elements for PC.3.10: Victims of abuse and neglect

HIM Connection, December 4, 2007

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The Joint Commission's (formerly JCAHO) documentation requirements from the Provision of Care (PC) chapter in the Comprehensive Accreditation Manual for Hospitals state in PC.3.10 elements of performance (EP) 1-7 that healthcare providers must assess a patient who may be the victim of abuse or neglect. This standard requires a policy that includes a clear explanation of the following:

• Criteria for identifying victims of abuse and neglect
• The process for assessment and referrals
• The education process (both orientation for new hires and annual education)
• The process for reporting this information internally and externally

A hospital's policy should clearly state when it is appropriate to conduct an assessment and make a referral. The policy should also include the referral list and contact information for those individuals. Hospitals should also establish a process to ensure immediate reporting of all confirmed or suspected cases of abuse or neglect. Once hospitals establish this process, they should include it in a written policy.

Hospitals must also define what the provider must document, as well as the specific location in the medical record where he or she must provide the information. Hospitals should determine whether they should secure the record. Remember that confidentiality and security of patient information is important to this standard even when The Joint Commission does not specifically state it in the standards.

This topic was adapted from the December issue of Medical Records Briefing. For more information, click here.

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