Catalog Number : ncd1609
Title : 2013 Joint Commission Record of Care Chapter
Speaker : Sue Dill

Webplay Recording Date : 3-14-2013
Webplay Price : $ 200 for two weeks viewing

Webinar Overview:

Did you know the most common area for hospitals to be out of compliance last year was in the Record of Care chapter? 61% of all hospitals surveyed last year were out of compliance with RC.01.01.01. Dating and timing all entries and verbal orders are a hot spot with both The Joint Commission and CMS in the Hospital Conditions of Participation. Come learn how to comply with this challenging standard and others.

Target Audience:

This program is for anyone involved in the documentation of patient care especially:

• Physicians
• Nurses
• Accreditation Director
• Director of Regulatory Affairs
• legal counsel and other health care providers
• Risk Managers
• Hospital Attorneys
• COO
• CNO
• Physician Assistants (PA)
• Nurse Practitioners (NP)
• Compliance Officers
• Joint Commission Coordinators
• quality and performance improvement staff
• policy and procedure committee members
• Case Managers
• Health Information Management Director and staff
• documentation specialist
• computer programmers
• Nurse Educators
• Nurse managers
• Patient Safety Officer
• audit committee
• others who participate in ensuring compliance with documentation requirements and the documentation process should attend

Webinar Objectives:

• Recall that as hospitals move toward an electronic medical record how important it is to be aware of the TJC standards so that these standards can be incorporated into fields for electronic charting
• Describe what TJC requires to be documented regarding verbal orders, history and physicals
• Discuss that the TJC required elements found in the Record of Care chapter should be incorporated into hospital forms and documents
• Recall that the hospital is required to audit its medical records
• Discuss that medical records must contain a summary list for each patient who receives continuing ambulatory care services
• Discuss the requirement on improving patient-provider communication that requires race and ethnicity to be documented on all patients including outpatients

Webinar Outline:

• 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 .01.05.01
  • 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
  • These are discussed in a separate program

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.