JCAHO requirements for documentation

  1. 1
    Our administration is telling us that we are required to include the images associated with the FACES scale on our paper documentation per JCAHO. Does anyone have a reference or citation for this?
    We cannot locate one and would like to remove it from our charts to save space.

    Thanks
    Esme12 likes this.
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  3. 5 Comments so far...

  4. 3
    in one word.......yes.

    if you are using the wong-baker scale (http://www.wongbakerfaces.org/)
    that utilizes picture then the pictures must be present. jacho (or just jc as they now wish to be called) don't care how you develop your policy or how simple or complicated the policy is as long as you can document result and outcome. if that policy includes picture then the pictures must be there. i can't release my source but suffice it to be from a reliable source that has personal knowledge from the inside of the jc. they have their favourite recommendations,and it behooves you to use their recommendations, but you must follow whatever you set out 100% of the time and be able to document it

    documentation is essential for supporting the patient evaluation, the overall pain management plan, any consultations received, and periodic review of the status of the patient. the essential tools for evaluating the use of controlled substances for pain management include an evaluation of the patient, a treatment plan, an informed consent and treatment agreement, a periodic review, consultation and medical records and jacho requirements

    pain assessment scales are useful for eliciting responses from patients about their comfort or discomfort, for enhancing clarity in communications, and for supporting an individualized pain management program especially if you use a facial recognition scale like the wong-baker faces pain rating scale which is especially useful for children and those who have a language barrier, this scale features a series of faces your patient can choose from that graphically depict his or her pain. the first face shows no pain (0) and the last face shows the most severe pain (5). you must depict the faces themselves if they are apart of the assessment tool.

    the primary purpose of the patient record is for documenting the care of the patient. whether the medical record format is paper-based or computer-based, him professionals strive to meet the challenges of documentation requirements. beyond the main purpose of the documentation of patient care, the medical record is a tool for collecting, storing, and processing patient information. records are being used daily for a multitude of purposes, including:

    • providing a means of communication between the physician and the other members of the healthcare team caring for the patient
    • providing a basis for evaluating the adequacy and appropriateness of care
    • providing data to substantiate insurance claims
    • protecting the legal interests of the patient, the facility, and the physician
    • providing clinical data for research and education

    general guidelines for patient record documentation

    • each hospital should have policies that ensure uniformity of both content and format of the patient record based on all applicable accreditation standards, federal and state regulations, payer requirements, and professional practice standards.
    • the patient record should be organized systematically to facilitate data retrieval and compilation.
    • only persons authorized by the hospital’s policies to document in the patient record should do so. this information should be recorded in the medical staff rules and regulations and/or the hospital’s administrative policies.
    • hospital policy and/or medical staff rules and regulations should specify who may receive and transcribe a physician’s verbal orders.
    • patient record entries should be documented at the time the treatment they describe is rendered.
    • authors of all entries should be clearly identifiable.
    • abbreviations and symbols in the patient record are permitted only when approved according to hospital and medical staff bylaws, rules, and regulations.
    • all entries in the patient records should be permanent.
    • errors should be corrected as follows: draw a single line in ink through the incorrect entry, and print "error" at the top of the entry with a legal signature or initials, date, time, title, reason for change, and discipline of the person making the correction. errors must never be obliterated. the existing entry should be left intact with corrections entered in chronological order. late entries should be labeled as such.
    • in the event the patient wishes to amend information in the record, it shall be done as an addendum, without change to the original entry, and shall be clearly identified as an additional document appended to the original patient record at the direction of the patient, who will thereafter bear responsibility for the explaining the change.
    • the health information department should develop, implement, and evaluate policies and procedures related to quantitative and qualitative analysis of patient records.
    • review any requirements outlined in state law, regulation, or healthcare facility licensure standards as they relate to documentation requirements. if your state requires that verbal orders be authenticated within a specified time frame, accrediting and licensing agencies will survey for compliance with that requirement.

    the joint commission, formerly known as the jcaho (joint commission on accreditation of healthcare organizations), is a nonprofit organization tasked with accreditation of hospitals and other health care organizations. it sets standards for accreditation and certification, and tracks patient safety and other performance measurements. among other standards, it sets documentation requirements for certification of health care staffing.

    http://www.ehow.com/list_7550000_jca...uirements.html

    read more: jcaho documentation requirements | ehow.com http://www.ehow.com/list_7550000_jca...#ixzz1bc0t9p63

    joint commission and conditions of participation standards
    jacho who now wished to be called just "the joint commision" now requires that........

    the medical record contains sufficient information to im.7.2 482.24 (c) identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among healthcare providers.
    im.7.2
    482.24 (c)

    this is lengthy but follow the link to see all of the requirements
    http://library.ahima.org/xpedio/grou...me=bok1_000031

    lengthy but i hope it helps. it's not the answer you wanted but an answer nonetheless.
    Last edit by Esme12 on Oct 23, '11
    tyvin, Ginger's Mom, and herring_RN like this.
  5. 0
    Thanks for your reply.
    This can really help.

    Followup question.
    How are those with electronic medical records handling this requirement?

    Our administration wants us to keep the FACES scale on our paper record so that when we utilize this scale we show it to the patient and they select the appropriate face.

    When we implement electronic records in the next few months we will not have the ability to take our patients to our computers to show them this scale.

    Is it acceptable to have a reference card with this scale, or a poster in each room?
  6. 0
    Quote from midge121787
    Thanks for your reply.
    This can really help.

    Followup question.
    How are those with electronic medical records handling this requirement?

    Our administration wants us to keep the FACES scale on our paper record so that when we utilize this scale we show it to the patient and they select the appropriate face.

    When we implement electronic records in the next few months we will not have the ability to take our patients to our computers to show them this scale.

    Is it acceptable to have a reference card with this scale, or a poster in each room?
    Yes, but that is very tricky to maintain 100% compliance and...... the policy needs to be changed to reflect the "new" policy of where the faces are available for the patient. When removed from "paper" the JC looks closer. The nicest I have seen posted was on the eraser boards in the room permanently fixed and "framed with the scale clearly labeled and easily posted......stating "Are you having pain" and the scale posted. The reference to where the faces are available to the patient must be referenced to in the policy....."The Wong-Baker" scale clearly posted in every room will be used for patient reference for pain".

    AND.....there must be some reference tool that is a part of the medical record independent of the hospital itself that references the pain scale so that if the4 chart is independently removed.....one could still understand what the pain scale means. I have seen it as a part of the order sets for pain management and control right on the order set iself as in right on a PCA order sheet but again it's getting 100% compliance from the MD's to use the sheet when you have a hard time getting them to comply with CAP and DVT .

    ....

    Which remains a compliance nightmare and many have left it apart of a paper flow record for compliance adherence issues to stay out of the JC's way.... Why ask the JC to look any deeper....
  7. 0
    Quote from midge121787
    Our administration is telling us that we are required to include the images associated with the FACES scale on our paper documentation per JCAHO. Does anyone have a reference or citation for this?
    We cannot locate one and would like to remove it from our charts to save space.

    Thanks
    JCAHO requirements for documentation

    What specific aspect of the documentation are they talking about? My only guess is pain scale. Different types of pain scales are used to determine the severity of the pain so that treatment can be appropriate. Since pain is the fifth vital sign it is important use the right tool based on age and the patients' mental status. The numeric scale is used when the the patient is alert and oriented, the faces are used for children and cognitively impaired older persons . Comatose patients pain responsed are measured by the patient response to painful stimuli. Generally the first step in assuring quality pain management is good and appropriate pain assessment. The challenges of recognizing pain in cognitively impaired older persons can be very difficult. Because of this, this is a genal concern JCAHO. ALL institutions must have a pain assessment method and the recommendations for effective pain management using a tested tools with intructions on assessing, documenting and monitoring pain in the general population and the cognitively impaired. During the pain assement the most widely used pain scales focus on visual, verbal, numerical or on utilizing combination of all all three forms of assessment based on the patient cognitive status. Since the proper pain management strive to improve the quality of pain care the pain assessment must include th following: 1. Pain Onset and temporal pattern When did your pain start? How often does it occur? Has its intensity changed? 2. Pain Location Where is your pain? Is there more than one site?
    3.Pain Description What does your pain feel like? What words would you use to
    describe your pain? 4. Pain Intensity On a scale of 0 to 10, with 0 being no pain and 10 being the worst
    pain you can imagine, how much does it hurt right now? How much does it hurt at its worst? How much does it hurt at its best? 5. Pain Aggravating and relieving factors What makes your pain better? What makes your pain worse? 6. Previous Pain treatment What types of treatment have you tried to relieve your pain? Were they and are they effective? 7.Pain Effect How does the pain affect physical and social function?

    The numeric pain scale



    Using the numeric scale pain is assessed on a scale of 0-10, with 0 being no pain and 10 being the worst pain.

    Wong-Baker FACES Pain Rating Scale: Point to each face using the words to describe the pain intensity. The child is asked to choose the face that best describes their own pain and record the appropriate number.
    The Wong-Baker Faces Pain Rating Scale


    Designed for children aged 3 years and older, the Wong-Baker Faces Pain Rating Scale is also helpful for elderly patients who may be cognitively impaired. If offers a visual description for those who do not have the verbal skills to explain how their symptoms make them feel.

    To use this scale, the technique must be explained to the child in his/her appropriate language letting him/her know that each face shows how a person in pain is feeling. That is, a person may feel happy because he or she has no pain (hurt), or a person may feel sad because he or she has some or a lot of pain.


    Face 0 is very happy because he or she doesn't hurt at all.
    Face 1 hurts just a little bit.
    Face 2 hurts a little more.
    Face 3 hurts even more.
    Face 4 hurts a whole lot.
    Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad.

    Sources

    American Pain Society [APS], 1992; Jackson, 1995; Jacox, Ferrell, Heidrich, Hester, &
    Miaskowski, 1992; McCaffery, Ferrell, O'Neil-Page, & Lester, 1990

    http://www.partnersagainstpain.com/h...ent/tools.aspx

    http://intqhc.oxfordjournals.org/content/16/1/59.full



    Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.
  8. 0
    Quote from cherrypie2
    JCAHO requirements for documentation

    What specific aspect of the documentation are they talking about? My only guess is pain scale. Different types of pain scales are used to determine the severity of the pain so that treatment can be appropriate. Since pain is the fifth vital sign it is important use the right tool based on age and the patients' mental status. The numeric scale is used when the the patient is alert and oriented, the faces are used for children and cognitively impaired older persons . Comatose patients pain responsed are measured by the patient response to painful stimuli. Generally the first step in assuring quality pain management is good and appropriate pain assessment. The challenges of recognizing pain in cognitively impaired older persons can be very difficult. Because of this, this is a genal concern JCAHO. ALL institutions must have a pain assessment method and the recommendations for effective pain management using a tested tools with intructions on assessing, documenting and monitoring pain in the general population and the cognitively impaired. During the pain assement the most widely used pain scales focus on visual, verbal, numerical or on utilizing combination of all all three forms of assessment based on the patient cognitive status. Since the proper pain management strive to improve the quality of pain care the pain assessment must include th following: 1. Pain Onset and temporal pattern When did your pain start? How often does it occur? Has its intensity changed? 2. Pain Location Where is your pain? Is there more than one site?
    3.Pain Description What does your pain feel like? What words would you use to
    describe your pain? 4. Pain Intensity On a scale of 0 to 10, with 0 being no pain and 10 being the worst
    pain you can imagine, how much does it hurt right now? How much does it hurt at its worst? How much does it hurt at its best? 5. Pain Aggravating and relieving factors What makes your pain better? What makes your pain worse? 6. Previous Pain treatment What types of treatment have you tried to relieve your pain? Were they and are they effective? 7.Pain Effect How does the pain affect physical and social function?

    The numeric pain scale

    Using the numeric scale pain is assessed on a scale of 0-10, with 0 being no pain and 10 being the worst pain.

    Wong-Baker FACES Pain Rating Scale: Point to each face using the words to describe the pain intensity. The child is asked to choose the face that best describes their own pain and record the appropriate number.
    The Wong-Baker Faces Pain Rating Scale

    Designed for children aged 3 years and older, the Wong-Baker Faces Pain Rating Scale is also helpful for elderly patients who may be cognitively impaired. If offers a visual description for those who do not have the verbal skills to explain how their symptoms make them feel.

    To use this scale, the technique must be explained to the child in his/her appropriate language letting him/her know that each face shows how a person in pain is feeling. That is, a person may feel happy because he or she has no pain (hurt), or a person may feel sad because he or she has some or a lot of pain.


    Face 0 is very happy because he or she doesn't hurt at all.
    Face 1 hurts just a little bit.
    Face 2 hurts a little more.
    Face 3 hurts even more.
    Face 4 hurts a whole lot.
    Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad.

    Sources

    American Pain Society [APS], 1992; Jackson, 1995; Jacox, Ferrell, Heidrich, Hester, &
    Miaskowski, 1992; McCaffery, Ferrell, O'Neil-Page, & Lester, 1990

    http://www.partnersagainstpain.com/h...ent/tools.aspx

    http://intqhc.oxfordjournals.org/content/16/1/59.full



    Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.

    They use wong baker they want to remove the faces picture reference from their documentation process and wsanted to know what the JC requires


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