Documentation Retention

Citation

TJC LD.13.01.01

The hospital complies with law and regulation.

The hospital must operate in accordance with all applicable laws and licensure requirements and maintain specific records for blood components.

Citation

TJC NPG.03.05.01

The hospital plans and conducts exercises to test its emergency operations plan and response...

The hospital plans and conducts exercises to test emergency operations and response procedures, including annual exercises for covered freestanding outpatient care buildings when not included in hospital exercises.

Citation

TJC NPG.07.02.01

The hospital honors the patient's right to give or withhold informed consent.

Requires the hospital to honor the patient's right to give or withhold informed consent through a written policy and a documented consent discussion covering proposed care, risks, benefits, alternatives, and surrogate decision-makers.

Citation

TJC NPG.09.01.01

The hospital uses standardized procedures for managing tissues.

Requires the hospital to use standardized written procedures for tissue acquisition, storage, supplier verification, temperature monitoring, and organ procurement notification.

Citation

TJC NPG.09.02.01

The hospital traces all tissues bi-directionally.

Requires the hospital to maintain records enabling bi-directional tracing of all tissues from donor or supplier to recipient or final disposition.

Citation

TJC NPG.10.01.01

Policies and procedures for waived tests are established, current, approved, and readily avai...

Requires the CLIA certificate holder to establish and maintain written, current, approved policies and procedures for waived testing addressing clinical use, quality control, specimen handling, instrument maintenance, and result reporting.

Citation

TJC NPG.14.05.01

The hospital maintains and communicates accurate patient medication information.

Requires the hospital to obtain, document, reconcile, and communicate accurate patient medication information across care transitions.

Citation

TJC PC.11.02.01

The hospital assesses and reassesses the patient and the patient's condition according to def...

Requires the hospital to assess and reassess patients within defined time frames, including initial assessments, medical history and physical examinations, and defined scope and content of screening.

Citation

TJC PC.13.01.03

The hospital provides the patient with care before and after operative or other high-risk pro...

Requires preanesthesia assessment, intraoperative and postanesthesia documentation, preprocedural education, immediate postoperative care, and qualified discharge.

Citation

TJC PC.14.02.03

When a patient is discharged or transferred, the hospital gives information about the care, t...

Requires the hospital to provide or transmit necessary medical information, including current course of illness, postdischarge goals, and treatment preferences, to receiving post-acute providers at discharge, transfer, or referral.

Citation

TJC PC.15.01.01

The hospital safely provides blood and blood components.

Requires the hospital to safely provide blood and blood components, including policies, quarantine, notification, and documentation when potentially HIV- or HCV-infectious units are identified.

Citation

TJC PE.03.01.01

The hospital designs and manages the physical environment to comply with the Life Safety Code.

Requires the hospital to design and manage its physical environment to comply with the Life Safety Code, including fire safety documentation, fire control plans, and construction-related safeguards.

Citation

TJC PE.03.02.01

The hospital protects occupants during periods when the Life Safety Code is not met or during...

Requires the hospital to implement interim life safety measures, including fire watches, alternative exits, surveillance, drills, and training, when Life Safety Code deficiencies cannot be immediately corrected or during construction.

Citation

TJC RC.11.01.01

The hospital maintains complete and accurate medical records for each individual patient.

Requires the hospital to maintain a complete and accurate medical record for every patient, with defined content, urgent-care documentation, and authenticated, legible, filed, and retained entries.

Citation

TJC RC.11.02.01

Entries in the medical record are authenticated.

Requires that all medical record entries, including verbal orders, be dated, timed, and authenticated by the responsible authorized practitioner, with safeguards protecting authentication integrity and record security.

Citation

TJC RC.11.03.01

The hospital retains its medical records.

Establishes that the hospital retains medical records in accordance with law, regulation, and hospital policy, with a five-year retention floor for deemed-status hospitals.

Citation

TJC RC.12.01.01

The medical record contains information that reflects the patient's care, treatment, and serv...

Specifies the demographic, clinical, consent, standing-order, and history-and-physical content that must be documented in the patient's medical record.

Citation

TJC TS.11.01.01

The hospital, with the medical staff’s participation, develops and implements written policie...

Requires the hospital, with medical staff participation, to develop and implement written policies and procedures for donating and procuring organs, tissues, and eyes, including OPO and tissue/eye bank agreements, donor family notification, and documentation of donation decisions.

Citation

TJC TS.12.01.01

The hospital complies with organ transplantation responsibilities.

Requires hospitals performing organ transplants to comply with OPTN rules and provide required transplant data to designated entities.