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COP 1 and 2

The document outlines standards for organizing patient care documentation at a hospital. Standard 1 discusses ensuring uniform care processes across departments by following standardized procedures. Standard 2 discusses systematically organizing patient documents in the medical record according to an assembly order so information can be easily retrieved. Documents should be sorted and filed according to this order, including separating bulky records into multiple volumes. Processes are described for handling documentation created during downtimes when electronic systems are unavailable.

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Kristel Jane Quito
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93 views

COP 1 and 2

The document outlines standards for organizing patient care documentation at a hospital. Standard 1 discusses ensuring uniform care processes across departments by following standardized procedures. Standard 2 discusses systematically organizing patient documents in the medical record according to an assembly order so information can be easily retrieved. Documents should be sorted and filed according to this order, including separating bulky records into multiple volumes. Processes are described for handling documentation created during downtimes when electronic systems are unavailable.

Uploaded by

Kristel Jane Quito
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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CARE OF PATIENTS

Standard 1 & 2
Prepared By:
KRISTEL JANE QUITO & ROBERT RAGUINI

11/8/20
11/8/20 1 1
CARE OF PATIENT STANDARD 1:
STANDARDIZATION OF CARE
• All hospitals/ facilities of AGH to provide a uniform care
processes across all departments and settings for patients
with the same care needs. The governing body and senior
leaders will provide the needed support to ensure the
implementation of one level quality care. Head of clinical
departments and other clinical leaders will work collaborative
way to meet the standards and procedures.
CARE OF PATIENTS – STANDARD 1
STANDARDIZATION OF CARE

 Intent OF COP.1

To implement the concept of “One Level of Quality of Care”;


where patients with the same health problems have the right to
the same quality of care throughout the organization.
To ensure the provision of uniform care processes; the following
standards and procedures must be followed in all areas where patient
care is provided.

 Access to and appropriateness of emergency care does not depend on


the patient's ability to pay or source of payment.
 Access to appropriate care and treatment by qualified practitioners will
be provided regardless of the time of the day or the day of the week.
 During all phases of care there is a qualified named individual identified
as responsible for the overall patient care
The patient will be assigned to a unit where equipment, resources and
staff expertise are appropriate for the patient’s
Any patient requiring specialized care must be assigned to the setting in the
facility where appropriate resources and expertise are available.
The care of each patient is individualized and planned by responsible
Physician/s, and nurses within 24 hours of admissions as inpatient. All health
team members shall coordinate their efforts to provide the planned care
based on the initial assessment and reassessment.
Any change in patient condition will result in a revision to the plan of care.
Patients and families are informed and educated about the plan of care and
outcome of treatment including any unanticipated outcomes of their care
and treatment.
Processes are developed within the facility to encourage multidisciplinary
interaction regarding patient care. Health care teams use tools and
techniques to ensure integrated and coordinated care for their patients.
The level of care provided to patients with the same care needs is
comparable throughout the organization.
Orders for care will only be written by those permitted to do so in the
facility and will be done only on the specified order form. Only physicians
are permitted to write orders for patient care.
Orders that must be written in the manual or electronic order form
include:  Medication orders, Nutritional orders, Intravenous fluid orders.
 Bedside monitoring tests like blood glucose or arterial blood gases. 
Orders for insertion and removal of peripheral intravenous catheters. 
Patient discharge or transfer order.  Orders for oxygen therapy.  Orders
for vital signs monitoring, continuous oxygen saturation monitoring,
cardiac monitoring and special neurological monitoring.
Clinical laboratory tests and radiology tests must be ordered by using
special forms that include indication and rationale for performing the
test.
 Orders, notes and Plan of Care activities must be easily accessible and in
a uniform location in the patient care record.
All procedures done will be clearly recorded in the patient’s file
where all care givers can find it. The results of the procedure will be
written in the medical record.
 Evidence-based clinical guidelines and clinical pathways are adopted
and followed as determined by specific departments or committees.
Care Planning and delivery must be integrated and co-ordained and
must be communicated among settings, departments, services and
disciplines. Discussions about patient condition must be documented.
CARE OF PATIENT STANDARD 2:
Assembly of Documents in the Medical Record

Patient Record must be organized according to the standard


assembly order, to maintain a systematic arrangement of
documents for easy retrieval of information. Assembly order
must be followed all the time to avoid jumbling of documents
leading to difficulty in reviewing the record by the health care
providers.
CARE OF PATIENTS – STANDARD 2
Assembly of Documents in the Medical Record

 Intent of COP 2
To ensure all forms and documents(all encounter types) with
medical records are systematically organized and readily available
in accordance with Health Information Management Practices and
documents retention requirements.
Assembly of Out Patient Records
Outpatient documents are arranged according to outpatient record order in
the reverse chronological order (most recent document on top), to facilitate
easy review of the recent records.
Loose reports received from ED by the HIM Staff daily in the morning such as
Financial Consent Forms, Copies of Insurance Cards, Identification documents,
Treatment Consent Forms, Referral forms, Police reports and ECGs.
Documents from Outpatient Clinics are received by HIM staff daily along with
the medical records.
All documents must be checked by the staff for the Medical Record Number,
FIN Number and name of the patient. Documents not having medical record
number and other identification data are sent back to the original source for
correction.
Sorting and filing of Loose Reports:
For fast flowing process, loose reports are sorted in applicable filing system.
Each document is verified with the name and MRN against the patient
record. If the demographic details on the document do not match with the
patient record, the document is sent back to the original source for
correction. Some documents may need to be tracked in Malaffi for record
locations.
When a loose report is received but the corresponding medical record is out
for appointment, the loose report is placed in out guide/designated folder in
HIM and filed on Main shelf to be checked again the next day and filed back
upon return to HIM. If the corresponding record is in the ward, the
document should be sent to the specific ward to be placed in patient chart
and the staff in the ward receiving the document must sign and
acknowledge the receipt. File
Assembly of Inpatient Records:
 All documents of patients admissions generated during the inpatient
wards/Day Surgery Unit stay will be filed according to the Standard
Assembly Order.
Assembly of Bulky Medical Record:
If recent admission makes the medical record bulky create additional volumes to
accommodate the admissions
Two or more folders may be needed in breaking up bulky medical records.
Standard Assembly Order must not be dismantled during separation process
Create media for additional volumes in Malaffi.
.In Malaffi perform Chart/visit Association to move recent admission/ encounter to its
present volume location.
Print new labels with the correct volume numbers and place them in the medical record
folder. Affix the corresponding label on each volume. The latest record shall be contained
in the latest volume.
For multiple volumes, a table of content is affixed on the inner left cover of the multiple
volumes for easy admissions references.
File the recent admission on the top. An appropriate admission divider is used to
separate from the previous admissions.
Assembly of “Down time” created records

The HIM Manager will control the creation and distribution of all new
Downtime medical record numbers.
 All new medical record numbers assigned during the Downtime period will
be cross checked with the Master Patient Index (MPI), once the system is
back on-line, to ensure that the patient doesn’t have an existing medical
record number.
In the event that the patient does have an existing medical record number
at any AGH facility, the two numbers (Downtime number and current,
active medical record number) will be associated by the HIM Department.
The Departments and units will be responsible for the maintenance
of the forms (e.g. specific Downtime forms and/or previously existing
order forms) to be used in the event of a Downtime incident.
.All Downtime medical record documentation forms must be
approved by the Forms/HIM Committee as these will be filed
permanently in the patient’s medical record as per approved
assembly order.
 Medical record forms used during Downtime events will be
maintained permanently in the paper medical record, regardless of
whether the information is entered into Malaffi or not.
THANK YOU

11/8/20
11/8/20 16 16

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