ContentJCAHO ALERT 2012 Information Management
PHI = Protected Health Information
Organization protects privacy, security, and integrity of PHI Agency staff provide security of information as required by HIPAA laws and agency policy Agency adheres to HIPPA regulations to safeguard PHI when using and Agency follows the minimum necessaryFax / email communications contcles PHI not visible through vehicle training.ssigned based upon job duties e reviewed on individual basis and in accordance with HIPAA laws and organizational process Organization effectively manages the collection of PHI Organization considers need for knowledge based information through The care and services provided
Links with internal information systems Links with external daJCAHO Alert Information Management 2012 Page 1 of 3 Information Management supports the orgaplanning, education, performance improvement, and patient and employee satisfaction, work flow improvements, and administrative decision makingOrganization uses standardized terminology, definitions, abbreviations, acronyms, symbOnly approved symbols / abbreviations are used in the clinical record Tabers Medical Dictionary is the reAgency staff are in compliance with use of abbreviations in the medical record Organization maintains accurate health information Permanent medical record contains accurate patient information and is patient admitted
Permanent medical record has a standardized format Permanent medical record contains essential data necessary to provide care/services to patients
HIPAA Compliance Manual Policy 2.1
Uses and Disclosure of PHI Policy 5.2 Information Management Plan Policy 5.3 Confidentiality Policy 5.7 Medical Record Format Policy 5.8 Medical Record Policy Policy 5.9 OASIS Correction Policy JCAHO Alert Information Management 2012 Page 2 of 3 JCAHO Standards out of compliance in 2009
1.The agency did not perform error corrections according to policy JCAHO Alert Information Management 2012 Page 3 of 3 personnel file with HIPAA access communications
Agency Annual HIPAA Audit completed to verify compliance with federal HIPAA regulations and Almost Family poPI Committee and are aVerify active and closed medical reCompliance upon hire and annu.
Medical record education module/A00; 00;[/00; ]00;/B00;x 00;[200;.300; 00;5.400;b 00;3.00; 400;.00;T ]00;/S00; /00; /00; /00;/A00; 00;[/00; ]00;/B00;x 00;[200;.300; 00;5.400;b 00;3.00; 400;.00;T ]00;/S00; /00; /00; /00;Page of Sutter Medical Center, SacramentoMedicaland Allied HealthStaffMedical Record DocumentationEducation ModuleKey requirements for providerdocumentation at SMCSSafe Patient CareCommunication is the keyDocumentation is the toolAt the conclusion of this education module, a quiz must be successfully completed.
Document Updated: 7/31/07; 8/21/07; 8/30/07; 11/12/10
/A00; 00;[/00; ]00;/B00;x 00;[200;.300; 00;5.400;b 00;3.00; 400;.00;T ]00;/S00; /00; /00; /00;/A00; 00;[/00; ]00;/B00;x 00;[200;.300; 00;5.400;b 00;3.00; 400;.00;T ]00;/S00; /00; /00; /00;Page of MEDICAL RECORD ENTRIES and LEGIBILITYThe Centers for Medicare & Medicaid Services(CMS) and the Joint Commission forAccreditation of Health Care Facilities (JCAHO) require ALLmedical record entries be GIBLE, TIMED, DATED and AUTHENTICATED In addition, SMCSMedical Staff Rules and applicable policiesstatethat all documentation in the medical record MUST be clearand legible.
The signature of the person making the entry shall be accompanied by the persons printed or stamped name or dictation numberfor purposes of authentication unless the authors signature is unequivocally legible.The standard used to determine legibility:Two staff must be able to read legibly in the medical record
.Date, time and sign and print or stamp your name or dictation number on all your medical record entries orders, notes, etc.
DO NOT PRE OR POST DATE ANY MEDICAL RECORD your orders with a nurse before you leave the nursing unit.This should alleviate confusion by allowing for immediate clarification.You can use a scribe as long as you immediately cosign your order or notes.The staff at SMCS cannot be used for this purposePLEASE NOTE:
You may anticipate being called by the unit nurse or the pharmacist for clarification of illegible and/or incomplete orders*Source:
CMS Interpretive Guidelines for Hospitals482.24(c)(1)JCAHO Hospital Accreditation Standard MM.3.20; Medical Staff Communication Policy
/A00; 00;[/00; ]00;/B00;x 00;[200;.300; 00;5.400;b 00;3.00; 400;.00;T ]00;/S00; /00; /00; /00;/A00; 00;[/00; ]00;/B00;x 00;[200;.300; 00;5.400;b 00;3.00; 400;.00;T ]00;/S00; /00; /00; /00;Page of ALL telephone medication ordersmust be authenticated 100% of the time within 48 hours.This is a state law:
California Code of Regulations, Title 22, Section 70263.It is also required by CMS and the JCAHO.
Authentication requires a date, timeand signature.The physician who gave the telephone order is responsible for assuring authentication of that order.
However, anyphysician participating in the care of the patient can authenticate the medication telephone order.
Important Note: The medical record will now be considered incomplete if you do not comply with the documentation requirement.Verbal orders are onlyaccepted under emergency nurse will read back the telephone order at the time it is given.
This is your opportunity to clarify or change the order.To ensure patient safety, your active participation is required in the readback of orders.Review the record for any telephone orders during your daily rounds; these are identified with a yellow sticker.
After reviewing the order, you must sign, date and time where indicated on the telephone The RN taking the order will place a yellow sticker at the bottom of the order, indicating the name of the person taking the order, the date and time.
There is a space for the physician to authenticate with signature, date and time.If there is any question about the telephone order, immediately bring it to the attention of the Charge RN.Source: 42 CFR 482.23(c)(2)(ii); CMS Position Statement April 19, 2001, California DHS Clarification to CCR Title 22, 70263(g) and 71233(g), California Business and Professions Code Section 4019, Medical Staff Rules and Regulations Section XXVIII, JCAHO Hospital Accreditation Standard IM.6.50, JCAHO National Patient Safety Goal 2A.
/A00; 00;[/00; ]00;/B00;x 00;[200;.300; 00;5.400;b 00;3.00; 400;.00;T ]00;/S00; /00; /00; /00;/A00; 00;[/00; ]00;/B00;x 00;[200;.300; 00;5.400;b 00;3.00; 400;.00;T ]00;/S00; /00; /00; /00;Page of UNSAFE ABBREVIATIONSPatient Safety is of critical importance to all who work in the health care field.Specific abbreviations attached to medications have resulted in patient harm due to medical error.
As a result, the Joint Commission now prohibits the use of these unsafe abbreviationsthroughout the medical record.
The Patient Safety Team and the Medical Executive Committee have approved this list.
UNSAFE SAFE UnitUnitZero absent before decimal point
.2 Leading zero before decimal point.
0.2Zero after decimal point
2.0 No zero after decimal point.
2 Q.D or Q.O.D.
Write daily or every other day MSMSO4MgSO4 Write morphine sulfate or magnesium sulfatec.c.Write ml for clear and legible medication orders using the safe The unsafe abbreviationlist is included on every order sheet and in the chart divider.Orders with unsafe abbreviationswill not be implemented.The order will have to rewritten by the ordering physician.Source: JCAH