Setting Standards for Health Records, Research Paper Example

Joint Commission on Accreditation of Healthcare Organizations: Setting standards for health records

The Joint Commission on Accreditation of Healthcare Organizations is responsible for setting standards for health records. Health records refer to any type of healthcare documentation provided by the healthcare service providers to an individual in the course of health care delivery (Joint Commission Resources Inc, 2005). The Joint Commission on Accreditation of Healthcare Organizations ensures that the health care records meet certain standards which are pertinent in capturing the required information as per the standards agreed upon with the healthcare service providers.

The Joint Commission on Accreditation of Healthcare Organizations stipulated in 2001 that all health care records should be structured and captures details pertaining to the patient’s personal details, laboratory test results, medical demographics as well as the financial information that will reflect the payments made by the patient to the health care service providers. The regulatory agencies also ensure that healthcare service providers maintain health care records that are up to date with every visit that the patient makes to the hospital.

For example, the Joint Commission on Accreditation of Healthcare Organizations ensures that the health records bears details of the last visit that the patient made in terms of the medical condition of the patient as per the last laboratory tests as well as the mode of payment that the patient used. It has become a norm for the Joint Commission on Accreditation of Healthcare Organizations to require the health records to bear the latest physical address of the patient. This is a requirement that came into effect in 2003 (Aspden, 2004).

In particular, in children’s healthcare clinics, details of the child’s parents are required to be updated with every visit. The Joint Commission on Accreditation of Healthcare Organizations also requires the healthcare records to have up-to-date information regarding the last vaccination or immunization given to the child. Furthermore, the regulatory agency stipulates that the name of the last nurse or doctor to see the child should appear clearly stated in the health records. Any referrals should also be clearly stated to enable the healthcare givers to succinctly follow through the child’s treatment and identify any allergies that the child may suffer from by looking at the child’s healthcare records (Aspden, 2004). Documentation of up-to-date health records is thus an imperative exercise.

There are several ways that healthcare organizations can implement to ensure compliance to the requirements of the Joint Commission on Accreditation of Healthcare Organizations relating to the maintenance of proper healthcare records. Firstly, the doctors should check and counter-check each of the patient’s health records before attending to and releasing the patient. This will ensure that any information missed out by the nurse is captured and records at this point in time. Perhaps it shall be key to modify the health records in paper so that vital information that has not been printed on the health records is captured. All old health records should then be transferred into the new health records with time. The use of temporary staff would be an important factor in this exercise.

Compliance to the requirements of the Joint Commission on Accreditation of Healthcare Organizations regarding the health records would also be made possible by training the relevant staff to be involved in the exercise. During the training, the importance of maintaining up-to-date health records should be emphasized (Joint Commission on Accreditation of Healthcare Organizations, 2002). This will facilitate the acceptance of the entire notion and hence guarantee the success of the whole exercise. Therefore, the Joint Commission on Accreditation of Healthcare Organizations should work in collaboration with the various stakeholders and healthcare givers to ensure that compliance with the health records requirement is not an uphill task. According to Carter (2008) making the health records to be electronic would be a more effective way of ensuring compliance that would go concurrently with the operations of the healthcare organizations.

References

Aspden, P. (2004). Patient safety: achieving a new standard for care. Washington: National Academies Press.

Carter, J.H. (2008). Electronic health records: a guide for clinicians and administrators. 2^nd ed. Berlin: ACP Press.

Joint Commission on Accreditation of Healthcare Organizations. (2002). Restraint and seclusion: complying with joint commission standards. New York: Joint Commission Resources.

Joint Commission Resources Inc. (2005). Patient safety: essentials for health care. 3^rd ed. London: Joint Commission Resources.

“Update: Guidelines for Defining the Legal Health Record for Disclosure Purposes.” AHIMA. RetrievedNovember 22, 2010 from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027921.hcsp?dDocName=bok1_027921