Health Information Management

Medical record documentation makes Joint Commission top 10 noncompliance list for first half of 2010

HIM Connection, November 9, 2010

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by Jean S. Clark, RHIA, CSHA

It should come as no surprise that medical record documentation made the list for top standards noncompliance for the first half of 2010. Our old favorites just won’t go away. 
 
Of all of the Joint Commission standards, RC.01.01.01 received the highest percentage of noncompliance among hospitals, with a score of 62%. Other standards that made the noncompliance list included:
  • RC.02.03.07 (verbal orders received and recorded by qualified staff): 31% 
  • PC.01.02.03 (patient is assessed and reassessed per defined time frames): 31%
  • MM.04.01.01 (clear and accurate medication orders): 30% 
Unfortunately, surveyors assess compliance with all of these standards and their Elements of Performance based on documentation in the medical record. Let’s review some of these troublesome standards and their corresponding EPs.
 
Note: To read more, visit the HCPro website. Subscribers to Medical Records Briefing have access to this article in the November issue of their newsletters.



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