Catalog Number : ncd1305
Title : Ensuring Compliance with TJC Record of Care
Speaker : Sue Dill

Webplay Recording Date : 1-18-2011
Webplay Price : $ 200 for two weeks viewing

Webinar Description:

This section is also referred to as the documentation chapter. This chapter summarizes what needs to be documented in the medical record. Hospitals should review this chapter when updated their assessment forms to ensure compliance.

The purpose of this program is to familiarize the attendee with the 2010 Joint Commission chapter on Record of Care. This was a new chapter in 2009 and there were amendments to eight of the eleven standards on July 1, 2009. These changes were made by the Joint Commission to come into closer compliance with the Center for Medicare and Medicaid Services (CMS) hospital conditions of participation (CoPs). The CoPs must be followed by every hospital that received Medicare or Medicaid reimbursement which is almost every hospital in America.

This chapter evolved primarily from sections which were found in the Information Management (IM) and Provision of Care, Treatment, and Services (PC). It will also cover the TJC FAQs on Record of Care. Every hospital should ensure they are in compliance with these documentation requirements and these elements should be incorporated into forms and assessment tools.

Target Audience:

• This program is for anyone involved in the medication process especially:
  • Pharmacists
  • Physicians
  • Nurses
• Patient Safety Officer
• Risk Managers
• Hospital Attorneys
• Compliance Officers
• Joint Commission Coordinators
• Quality and Performance Improvement Staff
• Chief Nursing Officer
• Policy and Procedure Committee Members
• Case Managers
• Nurse Educators
• Nurse Managers
• others who participate in the medication process

WebinarOutline:

• Complete and accurate medical record RC.01.01.01
  • Patient identification, diagnosis, standardized formats, dated, TIMED, every patient needs medical record
• Authentication of entries in the medical record RC.01.02.01
  • Ongoing review, delinquency rate, authentication process
  • Documentation in a timely manner RC.01.03.01 and .01.05.0
  • Retention time, hospital policy, original records release, history and physical
• Hospital retains its medical records RC.01.05.01
• Information to reflect care and treatment RC.02.01.01
  • Demographic information, clinical information required, advanced directives, medication orders, informed consent, allergies, vital signs, nursing notes, AMA, time of arrival to ED, reason for admission, discharge plan, complication, HAI, etc.
• Documentation of operative or high risk procedure RC.02.01.03
  • Moderate sedation, H&P, op report, postoperative assessment, discharge, preop diagnosis, postop diagnosis, date of surgery, type of anesthesia, total time in surgery, etc.
• Restraint and seclusion documentation RC.02.01.05
  • Behavioral health and non behavioral health
  • Order, assessment, rationale, debriefing, criteria to remove, deaths in restraints, monitoring, etc.
• Summary list for ambulatory care RC.02.01.07
  • Patient summary list requirements, updates, and accessibility
• Verbal Orders RC.02.03.07
  • P&P in writing, documentation, authentications, time frames, who can sign off verbal orders, top problematic standard, etc.
  • Discharge information RC.02.04.01 Requirements for discharge summary, procedure performed, condition at discharge, reason for admission, condition at discharge, etc.
• 8 standards left in Information Management Chapter
  • Plan for managing information
  • Plans for continuity of its information management process
  • Protection of health information privacy
  • Security and integrity of health information
  • Collection of health information
  • Retrieval, and dissemination of information in useful format
  • Information resources are available, current, and authoritative
  • Accurate health information must be maintained

Nursing Contact Hours:

This course has been approved for 1.8 Iowa Nursing Contact Hours. There is usually a reciprocal agreement between state associations to allow these to count for each state. If you have any questions, please ask your state association.

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.