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.
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.
this is lengthy but follow the link to see all of the requirements
lengthy but i hope it helps. it's not the answer you wanted but an answer nonetheless.