Editor's note: Each installment of Joint Commission Standards will review a chapter of the Comprehensive Accreditation Manual for Hospitals and may be distributed to staff as a teaching tool. Joint Commission Standards will be updated monthly online and appear regularly in print. The Management of Information (IM) chapter covers a number of issues.

IM.1.10 Information Management Planning

An assessment of the hospital's internal and external information needs is the basis for its information management processes. The assessment includes both the information and data needs, as well as the flow of information throughout the hospital. Although a formal written plan is not required, evidence of a planned approach for meeting information needs that support the hospital's goals and objectives is.

IM.2.10, IM. 2.20, IM. 2.30 Confidentiality and Security

Confidentiality of data and information is a hospitalwide responsibility and includes verbal, written and automated communication. It includes both patient and employee information related to clinical, financial and business matters. Information and data are captured, stored and retrieved in a timely manner without compromising confidentiality. Only authorized staff is allowed to gain access to data and information.

A disaster recovery plan is in place that addresses maintaining continuity of critical information flow if information systems were severely interrupted.

IM.3.10 Information Management Processes

Processes are in place that provide for capturing, organizing, storing, retrieving, processing and analyzing data and information. This includes meeting industry standards or hospital policies for uniform data definitions, data capture, display and transmission. Laws and regulations related to retention of information and data for a sufficient amount of time are met.

IM.4.10 Information-Based Decision-Making

Information management systems support clinical and strategic decision-making by providing information from the patient record, knowledge-based information sources, and comparative and aggregate data. Timely and effective performance-improvement activities, patient care, treatment and service decisions, as well as managerial and operational decisions, are dependent on information management process.

IM.5.10 Knowledge-Based Information

Knowledge-based information, current and authoritative, is readily available to hospital practitioners and staff to enable them to maintain and improve competency, assist in making clinical decisions, educate patients and families, and support performance improvement and research initiatives.

IM.6.10, IM.6.20, IM.6.30, IM.6.40, IM.6.50, IM.6.60 Patient-Specific Information

An accurate, complete medical record is maintained for both inpatients and outpatients who are assessed, cared for, treated or served. The record facilitates care and treatment and also acts as a financial and legal record. The medical record contains patient-specific information appropriate to the individual patient's care. The hospital has a process for providing access to relevant information from the patient record when needed for use in patient care, treatment or services.

Operative, other high-risk procedures and the use of moderate or deep sedation or anesthesia are thoroughly documented in the individual patient record. A summary list becomes part of the medical record for patients receiving continuing ambulatory care services. The list contains significant diagnoses, procedures, drug allergies and medications. This set of standards also addresses processes for accepting and transcribing verbal or telephone orders.

Challenges in IM Standards

IM. 6.10 The hospital has a complete and accurate medical record for patients assessed, cared for, treated or served.

Fifteen percent of all hospitals surveyed in 2006 did not meet one or more of the 16 required elements of performance. The problematic elements of performance include:

·  dating and signing, authenticating medical record entries (e.g., if the hospital defines a time frame requiring a signature within a specified number of hours, such as all telephone orders must be authenticated within 12 hours, then the time of the original entry and again at the time of authentication must be included with the dates and signature to assure compliance);

·  medical record review (i.e., on an ongoing basis, concurrent, at the point of care);

·  timeliness, readability (handwritten or printed) and consistency, especially documentation of findings between disciplines;

·  medical record delinquency; and

·  emergency care records.

IM.6.50 Designated qualified staff accept and transcribe verbal or telephone orders from authorized individuals.

Of the three elements of performance scored under this standard, authentication of verbal or telephone orders tends to be a compliance issue. Based on state law or regulation or hospital policy, verbal or telephone orders are authenticated within the specific time frame. n

Jean Kalemba was previously director of performance improvement at Mountainside Hospital, Montclair, NJ. She is skilled in developing and implementing programs to meet hospital regulatory agency requirements and has an excellent record in preparing organizations for licensing and accreditation surveys.