Medical Records

Citation

TJC EM.12.02.01

The hospital has a communications plan that addresses how it will initiate and maintain commu...

The hospital must maintain a communications plan that includes contact lists, reporting procedures, and methods for sharing patient information during emergencies.

Citation

TJC IM.11.01.01

The hospital plans for continuity of its information management processes.

The hospital must maintain policies and procedures to ensure the availability and security of medical records during emergencies and system interruptions.

Citation

TJC IM.12.01.01

The hospital protects the privacy and confidentiality of health information.

The hospital must implement policies to protect patient health information and ensure disclosures are authorized by law or patient consent.

Citation

TJC IM.12.01.03

The hospital maintains the security and integrity of health information.

The hospital must maintain written policies to ensure the security, integrity, and controlled access of health information.

Citation

TJC IM.13.01.01

The hospital records health information in standardized formats.

The hospital must use standardized terminology, definitions, and abbreviations in medical documentation to ensure consistency.

Citation

TJC IM.13.01.03

The hospital retrieves, disseminates, and transmits health information in useful formats.

The hospital must maintain a system for coding and indexing medical records to ensure timely access to patient information.

Citation

TJC IM.13.01.05

For hospitals that use Joint Commission accreditation for deemed status purposes:

The hospital must maintain operational electronic notification systems to exchange patient health information with other providers for care coordination.

Citation

TJC MM.11.01.03

The pharmacy is a resource for medication-related information.

The pharmacy must provide professional staff with access to information regarding drug therapy, interactions, and administration.

Citation

TJC MS.14.01.01

Medical staff bylaws address self-governance and accountability to the governing body.

The standard specifies required medical staff bylaw content for governance, membership, credentialing, privileging, examinations, committees, and fair hearing processes.

Citation

TJC MS.16.01.01

The organized medical staff oversees the quality of patient care, treatment, and services pro...

Addresses organized medical staff responsibility for care quality, privileges, patient safety, histories and physicals, emergency care policies, and selected radiology and nuclear medicine staff qualifications.

Citation

TJC MS.16.03.01

The organized medical staff leads and participates in organizationwide performance improvemen...

The organized medical staff must lead and participate in performance improvement activities addressing care quality, patient safety, pain management, opioid prescribing, records, and practitioner competence.

Citation

TJC NPG.01.04.01

The hospital has a process for handoff communication.

The hospital has a process for sharing patient information during internal handoffs, including an opportunity for discussion between sender and receiver.

Citation

TJC NPG.01.06.01

The hospital conducts a preprocedure verification process.

The standard addresses verification of the correct patient, procedure, and site and availability of required procedure-related items before a procedure.

Citation

TJC NPG.01.06.03

The hospital performs a time-out before the procedure.

The standard requires a standardized team time-out immediately before invasive procedures or incisions and documentation of its completion.

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.09.02.01

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.12.01.01

The hospital’s leadership team ensures that there is qualified ancillary staff required to me...

Hospital leadership ensures adequate qualified ancillary staff across service lines, including medical records, dietetic, pharmacy, infection prevention, and surgical services, with specified qualifications and supervision.

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.13.02.15

The hospital documents the use of restraint or seclusion.

The hospital must document the use of restraint or seclusion in the medical record, including patient behavior, interventions attempted, and patient response.

Citation

TJC PC.14.01.01

The hospital follows its process for discharging or transferring patients.

Requires the hospital to operate an effective discharge and transfer planning process that begins early, involves the patient and care team, addresses post-acute needs, and is regularly assessed.

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 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 RC.12.01.03

The patient’s medical record contains documentation on any operative or other high-risk proce...

Requires the medical record to contain an operating room register and an operative or high-risk procedure report documenting surgical and anesthesia details.