Countdown to 2004 JCAHO Survey: What You Need to Know
BWH’s next site survey from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is slated for January 2004. To help prepare nurses for the impending survey, BWH Nurse plans to publish regular articles on appropriate processes and standards that apply to Nursing.
All nurses, who have not been through a JACHO Survey, should work with their nurse managers to ensure understanding and expectations of the process.
PART I: Nursing Documentation
As nurses, we play a key role in the patient’s hospital stay, and documentation needs to reflect the contributions that we make to the patient’s care. Remember, an action taken on the patient’s behalf today, if not documented, cannot be proven when the medical record is reviewed next week or month.
A. Changes Since JCAHO 2001 Survey
In an effort to improve nursing documentation, a few committees were convened to identify strategies to assure compliance with documentation standards.
The Patient Admission Assessment form was revised with a new format that includes a plan of care section for each patient need requiring one. The form is color-coded to identify section(s) to be completed by: Care Coordination; Pre-Admission Test Center (PATC) and unit staff. (Of note, all elective surgical patients are screened by the PATC staff and, when possible, interviewed by Care Coordination prior to their admission). Further changes were also made to include the refinement of the falls risk assessment section to differentiate three levels of risk and the plan of care to be implemented based on the risk level.
The revised form is now implementated throughout the medical, surgical and intensive care units. Nursing management at the unit level will be providing nursing staff with education on the new form. Guidelines for use of the form have also been developed.
Additionally, a shorter version of this admission assessment form was trialed on Tower 12 for patients whose stay was anticipated to be less than 48 hours. The revised version of the shorter form is now available. Guidelines for its use have also been developed.
B. Need for Standardized Format
As we continue to review results of medical record audits conducted monthly by nurse managers and their staff, it is clear that we do not have a standardized format for documentation, and the placement of that data in the patient’s hospital record. In an effort to achieve this standardization, an interdisciplinary team (with representatives from Medicine, Nursing, Care Coordination; Nutrition, Rehabilitation Services, and the Center for Clinical Excellence) has developed a format, which provides for a standardized approach to the documentation of the care provided to patients. The format will include: daily goals of care; anticipated date of discharge, and outcomes of care. There will be a separate page for each day of the patient’s hospital stay and a section for each health care discipline to document. Use of this format will make it easier to assess the patient’s progress, in addition to improving our compliance with JCAHO standards.
Nursing documentation of the patient’s progress should capture the essence of the patient’s hospital stay that includes: patient’s understanding of treatment; assessment of patient’s response to diagnostic and treatment procedures; patient-family education; preparation for discharge; and post-discharge needs (where indicated).
Look for more JCAHO articles in future issues of BWH Nurse. Suggestions for topics are welcome via email (cbreen1@partners.org).