Health Information Management

Ask the expert: Will an organization receive a requirement for improvement if a contracted service uses "do not use" abbreviations in its documentation in the medical records?

HIM-HIPAA Insider, September 11, 2007

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A: According to The Joint Commission's Frequently Asked Questions (FAQ) related to the 2007 National Patient Safety Goals (updated 1/07):

An accredited organization is held accountable for the performance of its "contracted services," so if a contracted service uses "do not use" terms in the medical/clinical/case records of the organization's patients/clients/residents, the organization will receive a RFI. In situations where the organization does not have a contractual or other accountable relationship, such as a home care service's referring physicians, the organization will only be required to inform the practitioners about the safety goal expectations and encourage them to comply.

To view the FAQ, visit http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals and click on "goal two."



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