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Comply with the IM.4.10 standard

HIM Connection, August 16, 2005

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The standard under the JCAHO's information-based decision-making section addresses the need to have information management (IM) systems to provide information for use in decision-making. There are seven elements of performance (EPs) and the first five are scored as Category C. They require a measure of success when the JCAHO determines the organization was not in compliance.

What does IM.4.10 mean?

1. EPs 1-5 require that information in the medical record must meet the following criteria to support clinical decision-making:
   • readily accessible throughout the system
   • accurately recorded
   • complete
   • organized for efficient retrieval of data
   • timely

2. Comparative performance data must be available for decision-making. (This is scored as a Category B.)

3. The hospital must be able to collect and aggregate certain data and information to support care, treatment and service delivery and operations. (This is scored as a Category B.)

How to comply with the standard

The medical records committee establishes standards for patient record keeping, both for the paper record and the electronic components. A standard format establishes the order of documents contained in the records.

Hospital policy dictates that accuracy is paramount and there is a standard approach to correcting errors; they are identified as errors by the author and the correct information is then added. Nothing is ever removed from the record.

The organization makes sure that records are available at all times for patient care, either online or in paper form. Pertinent parts of the record can be retrieved from off-site ambulatory locations if needed. Time requirements apply to many components of the record and the organization monitors compliance.

To meet the EP on comparative data, the organization may use run charts to compare current performance to past performance over a time continuum. Quarterly financial reports are another way the organization compares performance over time. Interactive comparative databases compare the organization's performance to the performance of a healthcare organization of similar size and complexity. Most states also require hospitals to submit data to a database and the JCAHO and Medicare require specific indicators for comparison across hospitals.

To assure compliance with EP 7, the hospital must collect and aggregate data to support the following:

• Individual care, treatment, and services and care, treatment, and service delivery
• Decision-making
• Management and operations
• Analysis of trends over time
• Performance comparisons over time within the hospital and with other organizations
• Performance improvement
• Infection control
• Patient safety

Editor's note: This article is adapted from the soon-to-be-published book Information Management: The Compliance Guide to the JCAHO standards, 5th edition by Jean S. Clark, RHIA. To order your copy now, call our Customer Service Department at 800.650.6787.

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