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Patient-specific information and the IM.6.10 standard

HIM Connection, June 22, 2004

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IM.6.10 addresses the medical record and specific requirements for some of its content, staff allowed to make entries, and time frames for completion. The following 14 elements of performance outline expectations for this standard:

1. The hospital ensures that only authorized individuals make entries in the medical record.

2. Hospital policy stipulates when countersignatures are needed for entries made by nonindependent practitioners.

3. The hospital uses standardized formats to document all care, treatment, and services that patients receive.

4. Hospital policy requires that every medical record entry is dated, identifies the author, and authenticated when necessary.

5. The hospital authenticates history and physical examinations, operative reports, consultations, or discharge summary by written or electronic signature, or a computer key or rubber stamp.

6. Medical record information identifies the patient, supports the diagnosis, justifies the treatment and services, documents the course and result of care, and promotes continuity of care.

7. The content of the discharge summary includes reason for admission, key findings, any procedures or treatments performed, condition at discharge, and discharge instructions.

8. Hospital policy establishes time requirements for various elements of the record.

9. Hospital policy establishes time requirements for completion of the entire record no more than 30 days after the patient is discharged.

10. The medical record delinquency rate is measured at regular intervals, but no more than every quarter.

11. The organization conducts record review at the point of service using predetermined, defined measures that consider consistency, clarity, timeliness, accuracy, legibility, quality, and presence of all requirements.

12. The organization establishes retention and use requirements consistent with state and federal laws and regulations.

13. The organization establishes conditions under which an original medical record may be released for removal, which usually is under court order or subpoena.

14. Patients seen at the emergency department have the following information included in  their records: time and mode of arrival, disposition and condition upon conclusion of treatment in the emergency department, discharge instructions, whether the patient left without being seen or against medical advice, and a statement that a copy of the record is available to the practitioner responsible for follow-up care.

Write clear policies that describe the requirements for inpatient and ambulatory medical-record keeping. The policy should define time limits for completion, authentication, format, and sufficient information. Either the same policy or a separate policy should stipulate retention and release requirements. The emergency department documentation policies usually stipulate the special requirements for that department. Compliance with the policies is monitored through ongoing record review.

This excerpt is adapted from the book Information Management: The Compliance Guide to the JCAHO Standards, Fourth Edition. Click here to order or learn more.

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