Date(s):  August 05, 2009
Time:  12:00 p.m. - 1:30 p.m. CENTRAL TIME

View PDF Associated With This Event

Overview: The purpose of this program is to familiarize the listener with the new 2009 Joint Commission chapter on Record of Care. This program will also cover the eight changes that will be effective July 1, 2009. These changes were made by the Joint Commission to come into closer compliance with the Center for Medicare and Medicaid Services (CMS) hospital conditions of participation (CoPs). The CoPs must be followed by every hospital that received Medicare or Medicaid reimbursement which is almost every hospital in America. This chapter evolved primarily from sections which were found in the Information Management (IM) and Provision of Care, Treatment, and Services (PC). It will also cover the TJC FAQs on Record of Care. Every hospital should ensure they are in compliance with these documentation requirements and these elements should be incorporated into forms and assessment tools. This chapter was part of the standards improvement initiative (SII) which also resulted in a new numbering system in 2009.

Objectives:
• Recall that the Joint Commission has a new chapter in 2009 on documentation requirements called the Record of Care chapter,
• Describe what TJC requires to be documented regarding verbal orders and history and physicals,
• Discuss how TJC required elements should be incorporated into hospital forms and documents,
• Describe that the TJC has changes on documentation that go into effect July 1, 2009 to help bring the TJC standards into closer compliance with the CMS hospital Conditions of Participation.

Topics:
• Complete and accurate medical record RC.01.01.01,
o Patient identification, diagnosis, standardized formats, dated, TIMED, every patient needs medical record,
• Authentication of entries in the medical record RC.01.02.01,
o Ongoing review, delinquency rate, authentication process,
• Documentation in a timely manner RC.01.03.01 and .01.05.01
o Retention time, hospital policy, original records release, history and physical
• Information to reflect care and treatment RC.02.01.01
o 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
o 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
o Behavioral health and non behavioral health
o Order, assessment, rationale, debriefing, criteria to remove, deaths in restraints, monitoring, etc.,
• Summary list for ambulatory care RC.02.01.07
o Patient summary list requirements, updates, and accessibility,
• Verbal Orders RC.02.03.07
o P&P in writing, documentation, authentications, time frames, who can sign off verbal orders, top problematic standard, etc.,
• Discharge information RC.02.04.01
o Requirements for discharge summary, procedure performed, condition at discharge, reason for admission, condition at discharge, etc.,

Target Audience: Anyone involved in the documentation of patient care especially physicians, nurses and other health care providers. RMs, hospital attorneys, compliance officers, Joint Commission coordinators and quality and performance improvement staff, CNOs, policy and procedure committee members, case managers, nurse educators, nurse managers, audit committee, and others who participate in ensuring compliance with documentation requirements and the documentation process should attend. This program is a must attend for the Health Information Management director and staff.

Faculty: Sue Dill Calloway is a nurse attorney and is director of hospital risk management for OHIC Insurance Company. She has done many educational programs or nurses, physicians and other healthcare providers. She has authored over 100 books including a book by HCPro on the Compliance Guide to the Joint Commission and CMS Patient Rights Standards and 2009 Joint Commission Leadership standards.

Registration: Educate Your Entire Staff Quickly and Economically!
Register for this program to educate your entire staff in a short period of time without incurring multiple registration fees or travel expenses. The registration is $195 and includes one toll-free telephone connection and one free internet connection to the presentation. You can gather numerous staff members in one room to “attend” for one economical price. Prior to the program, you will receive a detailed slide presentation and handout materials which you can distribute to all participants, along with the log-in information.

Click here to register

For More Information:
Jon Borton
Phone: (402) 742-8147
E-mail: jborton@nhanet.org