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EP_Review_Prepub_Disposition_HAP_IM_PI_RC_20180108pdfnew.pdf
Hospital (HAP) Accreditation Program
Standard Changes Related to EP Review Phase IV
Issued January 17, 2018
Information Management (IM) Chapter
The hospital plans for continuity of its information management processes.
Standard IM.01.01.03 Requirement Text:
The hospital has a written plan for managing interruptions to its information processes (paper-based, electronic, or a mix of paper-based and electronic). (See also EM.01.01.01, EP 6)
1IM.01.01.03
Current EP Text:
EP:
Revision Type:
The hospital follows a written plan for managing interruptions to its information processes (paper-based, electronic, or a mix of paper-based and electronic). (See also EM.01.01.01, EP 6)
1IM.01.01.03
New EP Text:
EP:
Revised
The hospital's plan for managing interruptions to information processes addresses the following: Scheduled and unscheduled interruptions of electronic information systems. (See also IM.03.01.01, EP 1; EM.01.01.01, EP 6)
2IM.01.01.03
Current EP Text:
EP:
Revision Type:
The hospital's plan for managing interruptions to information processes addresses the following: - Scheduled and unscheduled interruptions of electronic information systems (See also IM.03.01.01, EP 1) - Training for staff and licensed independent practitioners on alternative procedures to follow when electronic information systems are unavailable - Backup of electronic information systems (See also EM.01.01.01, EP 6)
2IM.01.01.03
New EP Text:
EP:
Consolidated
Page 1 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
Hospital (HAP) Accreditation Program Issued January 17, 2018
The hospital's plan for managing interruptions to information processes addresses the following: Training for staff and licensed independent practitioners on alternative procedures to follow when electronic information systems are unavailable. (See also EM.01.01.01, EP 6)
3IM.01.01.03
Current EP Text:
EP:
Revision Type:
The hospital's plan for managing interruptions to information processes addresses the following: - Scheduled and unscheduled interruptions of electronic information systems (See also IM.03.01.01, EP 1) - Training for staff and licensed independent practitioners on alternative procedures to follow when electronic information systems are unavailable - Backup of electronic information systems (See also EM.01.01.01, EP 6)
2IM.01.01.03
New EP Text:
EP:
Consolidated
The hospital's plan for managing interruptions to information processes addresses the following: Backup of electronic information systems. (See also EM.01.01.01, EP 6)
4IM.01.01.03
Current EP Text:
EP:
Revision Type:
The hospital's plan for managing interruptions to information processes addresses the following: - Scheduled and unscheduled interruptions of electronic information systems (See also IM.03.01.01, EP 1) - Training for staff and licensed independent practitioners on alternative procedures to follow when electronic information systems are unavailable - Backup of electronic information systems (See also EM.01.01.01, EP 6)
2IM.01.01.03
New EP Text:
EP:
Consolidated
The hospital protects the privacy of health information.
Standard IM.02.01.01 Requirement Text:
The hospital has a written policy addressing the privacy of health information. (See also RI.01.01.01, EP 7)
1IM.02.01.01
Current EP Text:
EP:
Revision Type:
The hospital follows a written policy addressing the privacy of health information. (See also RI.01.01.01, EP 7)
1IM.02.01.01
New EP Text:
EP:
Consolidated
The hospital implements its policy on the privacy of health information. (See also RI.01.01.01, EP 7)
2IM.02.01.01
Current EP Text:
EP:
Revision Type:
The hospital follows a written policy addressing the privacy of health information. (See also RI.01.01.01, EP 7)
1IM.02.01.01
New EP Text:
EP:
Consolidated
Page 2 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
Hospital (HAP) Accreditation Program Issued January 17, 2018
The hospital maintains the security and integrity of health information.
Standard IM.02.01.03 Requirement Text:
The hospital has a written policy that addresses the security of health information, including access, use, and disclosure.
1IM.02.01.03
Current EP Text:
EP:
Revision Type:
The hospital follows a written policy that addresses the security of health information, including access, use, and disclosure.
1IM.02.01.03
New EP Text:
EP:
Revised
The hospital has a written policy addressing the integrity of health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction.
2IM.02.01.03
Current EP Text:
EP:
Revision Type:
The hospital implements a written policy addressing the following: - Maintaining the integrity of health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction - The intentional destruction of health information - When and by whom the removal of health information is permitted Note: Removal refers to those actions that place health information outside the hospital's control.
2IM.02.01.03
New EP Text:
EP:
Consolidated
The hospital has a written policy addressing the intentional destruction of health information.
3IM.02.01.03
Current EP Text:
EP:
Revision Type:
The hospital implements a written policy addressing the following: - Maintaining the integrity of health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction - The intentional destruction of health information - When and by whom the removal of health information is permitted Note: Removal refers to those actions that place health information outside the hospital's control.
2IM.02.01.03
New EP Text:
EP:
Consolidated
Page 3 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
Hospital (HAP) Accreditation Program Issued January 17, 2018
The hospital has a written policy that defines when and by whom the removal of health information is permitted. Note: Removal refers to those actions that place health information outside the hospital's control.
4IM.02.01.03
Current EP Text:
EP:
Revision Type:
The hospital implements a written policy addressing the following: - Maintaining the integrity of health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction - The intentional destruction of health information - When and by whom the removal of health information is permitted Note: Removal refers to those actions that place health information outside the hospital's control.
2IM.02.01.03
New EP Text:
EP:
Consolidated
Performance Improvement (PI) Chapter
The hospital collects data to monitor its performance.
Standard PI.01.01.01 Requirement Text:
The leaders set priorities for data collection. (See also LD.04.04.01, EP 1)
1PI.01.01.01
Current EP Text:
EP:
Revision Type:
The leaders (including the governing body) set priorities for and identify the frequency of data collection. (See also LD.04.04.01, EP 1)
1PI.01.01.01
New EP Text:
EP:
Consolidated
The leaders identify the frequency for data collection. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The leaders that specify the frequency and detail of data collection is the governing body.
2PI.01.01.01
Current EP Text:
EP:
Revision Type:
The leaders (including the governing body) set priorities for and identify the frequency of data collection. (See also LD.04.04.01, EP 1)
1PI.01.01.01
New EP Text:
EP:
Consolidated
The hospital collects data on the following: Performance improvement priorities identified by leaders. (See also LD.04.04.01, EP 1)
3PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on the following: Performance improvement priorities identified by leaders. (See also LD.04.04.01, EP 1)
2PI.01.01.01
New EP Text:
EP:
Moved
Page 4 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
Hospital (HAP) Accreditation Program Issued January 17, 2018
The hospital collects data on the following: Operative or other procedures that place patients at risk of disability or death. (See also LD.04.04.01, EP 2; MS.05.01.01, EP 6)
4PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on the following: Operative or other procedures that place patients at risk of disability or death. (See also LD.04.04.01, EP 2; MS.05.01.01, EP 6)
3PI.01.01.01
New EP Text:
EP:
Moved
The hospital collects data on the following: All significant discrepancies between preoperative and postoperative diagnoses, including pathologic diagnoses.
5PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on the following: All significant discrepancies between preoperative and postoperative diagnoses, including pathologic diagnoses.
4PI.01.01.01
New EP Text:
EP:
Moved
The hospital collects data on the following: Adverse events related to using moderate or deep sedation or anesthesia. (See also LD.04.04.01, EP 2)
6PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on the following: Adverse events related to using moderate or deep sedation or anesthesia. (See also LD.04.04.01, EP 2)
5PI.01.01.01
New EP Text:
EP:
Moved
The hospital collects data on the following: The use of blood and blood components. (See also LD.04.04.01, EP 2)
7PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on the following: The use of blood and blood components. (See also LD.04.04.01, EP 2)
6PI.01.01.01
New EP Text:
EP:
Moved
The hospital collects data on the following: All reported and confirmed transfusion reactions. (See also LD.04.04.01, EP 2; LD.04.04.05, EP 6)
8PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on the following: All reported and confirmed transfusion reactions. (See also LD.04.04.01, EP 2; LD.04.04.05, EP 6)
7PI.01.01.01
New EP Text:
EP:
Moved
The hospital collects data on the following: The results of resuscitation. (See also LD.04.04.01, EP 2)
11PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on the following: The results of resuscitation. (See also LD.04.04.01, EP 2)
10PI.01.01.01
New EP Text:
EP:
Moved
Page 5 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
Hospital (HAP) Accreditation Program Issued January 17, 2018
The hospital collects data on the following: Significant medication errors. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1)
14PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on the following: Significant medication errors. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1)
12PI.01.01.01
New EP Text:
EP:
Moved
The hospital collects data on the following: Significant adverse drug reactions. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1)
15PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on the following: Significant adverse drug reactions. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1)
13PI.01.01.01
New EP Text:
EP:
Moved
The hospital collects data on the following: Patient perception of the safety and quality of care, treatment, or services.
16PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on the following: Patient perception of the safety and quality of care, treatment, or services.
14PI.01.01.01
New EP Text:
EP:
Moved
For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home collects data on the following: Disease management outcomes.
40PI.01.01.01
Current EP Text:
EP:
Revision Type:
For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home collects data on the following: Disease management outcomes.
28PI.01.01.01
New EP Text:
EP:
Moved
For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home collects data on the following: Patient access to care within time frames established by the hospital.
41PI.01.01.01
Current EP Text:
EP:
Revision Type:
For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home collects data on the following: Patient access to care within time frames established by the hospital.
29PI.01.01.01
New EP Text:
EP:
Moved
Page 6 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
Hospital (HAP) Accreditation Program Issued January 17, 2018
For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home collects data on the following: - Patient experience and satisfaction related to access to care, treatment, or services, and communication - Patient perception of the comprehensiveness of care, treatment, or services - Patient perception of the coordination of care, treatment, or services - Patient perception of the continuity of care, treatment, or services (Refer to PI.01.01.01, EP 16)
42PI.01.01.01
Current EP Text:
EP:
Revision Type:
For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home collects data on the following: - Patient experience and satisfaction related to access to care, treatment, or services, and communication - Patient perception of the comprehensiveness of care, treatment, or services - Patient perception of the coordination of care, treatment, or services - Patient perception of the continuity of care, treatment, or services (Refer to PI.01.01.01, EP 16)
30PI.01.01.01
New EP Text:
EP:
Moved
The hospital collects data on patient thermal injuries that occur during magnetic resonance imaging exams.
46PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on patient thermal injuries that occur during magnetic resonance imaging exams.
34PI.01.01.01
New EP Text:
EP:
Moved
The hospital collects data on the following: - Incidents where ferromagnetic objects unintentionally entered the magnetic resonance imaging (MRI) scanner room - Injuries resulting from the presence of ferromagnetic objects in the MRI scanner room
47PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on the following: - Incidents where ferromagnetic objects unintentionally entered the magnetic resonance imaging (MRI) scanner room - Injuries resulting from the presence of ferromagnetic objects in the MRI scanner room
35PI.01.01.01
New EP Text:
EP:
Moved
The hospital collects data on pain assessment and pain management including types of interventions and effectiveness.
56PI.01.01.01
Current EP Text:
EP:
Revision Type:
The hospital collects data on pain assessment and pain management including types of interventions and effectiveness.
40PI.01.01.01
New EP Text:
EP:
Moved
Page 7 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
Hospital (HAP) Accreditation Program Issued January 17, 2018
Record of Care, Treatment, and Services (RC) Chapter
The hospital maintains complete and accurate medical records for each individual patient.
Standard RC.01.01.01 Requirement Text:
The medical record contains the information needed to support the patient’s diagnosis and condition.
5RC.01.01.01
Current EP Text:
EP:
Revision Type:
The medical record includes the following: - Information needed to support the patient’s diagnosis and condition - Information needed to justify the patient’s care, treatment, and services - Information that documents the course and result of the patient's care, treatment, and services - Information about the patient’s care, treatment, and services that promotes continuity of care among providers Note: For hospitals that elect The Joint Commission Primary Care Medical Home option: This requirement refers to care provided by both internal and external providers.
5RC.01.01.01
New EP Text:
EP:
Consolidated
The medical record contains the information needed to justify the patient’s care, treatment, and services.
6RC.01.01.01
Current EP Text:
EP:
Revision Type:
The medical record includes the following: - Information needed to support the patient’s diagnosis and condition - Information needed to justify the patient’s care, treatment, and services - Information that documents the course and result of the patient's care, treatment, and services - Information about the patient’s care, treatment, and services that promotes continuity of care among providers Note: For hospitals that elect The Joint Commission Primary Care Medical Home option: This requirement refers to care provided by both internal and external providers.
5RC.01.01.01
New EP Text:
EP:
Consolidated
Page 8 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
Hospital (HAP) Accreditation Program Issued January 17, 2018
The medical record contains information that documents the course and result of the patient's care, treatment, and services. (See also PC.01.02.07, EP 7)
7RC.01.01.01
Current EP Text:
EP:
Revision Type:
The medical record includes the following: - Information needed to support the patient’s diagnosis and condition - Information needed to justify the patient’s care, treatment, and services - Information that documents the course and result of the patient's care, treatment, and services - Information about the patient’s care, treatment, and services that promotes continuity of care among providers Note: For hospitals that elect The Joint Commission Primary Care Medical Home option: This requirement refers to care provided by both internal and external providers.
5RC.01.01.01
New EP Text:
EP:
Consolidated
The medical record contains information about the patient’s care, treatment, or services that promotes continuity of care among providers. Note: For hospitals that elect The Joint Commission Primary Care Medical Home option: This requirement refers to care provided by both internal and external providers.
8RC.01.01.01
Current EP Text:
EP:
Revision Type:
The medical record includes the following: - Information needed to support the patient’s diagnosis and condition - Information needed to justify the patient’s care, treatment, and services - Information that documents the course and result of the patient's care, treatment, and services - Information about the patient’s care, treatment, and services that promotes continuity of care among providers Note: For hospitals that elect The Joint Commission Primary Care Medical Home option: This requirement refers to care provided by both internal and external providers.
5RC.01.01.01
New EP Text:
EP:
Consolidated
All entries in the medical record are dated.
11RC.01.01.01
Current EP Text:
EP:
Revision Type:
All entries in the medical record are dated.
7RC.01.01.01
New EP Text:
EP:
Moved
For hospitals that use Joint Commission accreditation for deemed status purposes: All entries in the medical record, including all orders, are timed.
19RC.01.01.01
Current EP Text:
EP:
Revision Type:
For hospitals that use Joint Commission accreditation for deemed status purposes: All entries in the medical record, including all orders, are timed.
13RC.01.01.01
New EP Text:
EP:
Moved
Page 9 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
Hospital (HAP) Accreditation Program Issued January 17, 2018
Documentation in the medical record is entered in a timely manner.
Standard RC.01.03.01 Requirement Text:
The hospital defines the time frame for completion of the medical record, which does not exceed 30 days after the patient’s discharge.
2RC.01.03.01
Current EP Text:
EP:
Revision Type:
The hospital defines the time frame for completion of the medical record, which does not exceed 30 days after the patient’s discharge.
1RC.01.03.01
New EP Text:
EP:
Moved
The hospital has a written policy that requires timely entry of information into the medical record. (See also PC.01.02.03, EP 1)
1RC.01.03.01
Current EP Text:
EP:
Revision Type:
The hospital follows its written policy requiring timely entry of information into the patient’s medical record. (See also PC.01.02.03, EP 2)
2RC.01.03.01
New EP Text:
EP:
Consolidated
The hospital implements its policy requiring timely entry of information into the patient’s medical record. (See also PC.01.02.03, EP 2)
3RC.01.03.01
Current EP Text:
EP:
Revision Type:
The hospital follows its written policy requiring timely entry of information into the patient’s medical record. (See also PC.01.02.03, EP 2)
2RC.01.03.01
New EP Text:
EP:
Consolidated
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital records the patient's medical history and physical examination, including updates, in the medical record within 24 hours after registration or inpatient admission but prior to surgery or a procedure requiring anesthesia services.
4RC.01.03.01
Current EP Text:
EP:
Revision Type:
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital records the patient's medical history and physical examination, including updates, in the medical record within 24 hours after registration or inpatient admission but prior to surgery or a procedure requiring anesthesia services.
3RC.01.03.01
New EP Text:
EP:
Moved
Page 10 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
Hospital (HAP) Accreditation Program Issued January 17, 2018
The medical record contains information that reflects the patient's care, treatment, and services.
Standard RC.02.01.01 Requirement Text:
For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: Progress notes are recorded by the following individuals involved in the active treatment of the patient: - The doctor of medicine or osteopathy responsible for the care of the inpatient - A nurse - A social worker - Others involved in active treatment modalities The above individuals record progress notes at least weekly for the first two months of a patient’s stay and at least monthly thereafter. The progress notes include recommendations for revisions in the plan of care as indicated, as well as a precise assessment of the patient’s progress in accordance with the original or revised plan of care.
10RC.02.01.01
Current EP Text:
EP:
Revision Type:
For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: Progress notes are recorded by the following individuals involved in the active treatment of the patient: - The doctor of medicine or osteopathy responsible for the care of the inpatient - A nurse - A social worker - Others involved in active treatment modalities The above individuals record progress notes at least weekly for the first two months of a patient’s stay and at least monthly thereafter. The progress notes include recommendations for revisions in the plan of care as indicated, as well as a precise assessment of the patient’s progress in accordance with the original or revised plan of care.
7RC.02.01.01
New EP Text:
EP:
Moved
The medical record of a patient who receives urgent or immediate care, treatment, and services contains all of the following: - The time and means of arrival - Indication that the patient left against medical advice, when applicable - Conclusions reached at the termination of care, treatment, and services, including the patient's final disposition, condition, and instructions given for follow-up care, treatment, and services - A copy of any information made available to the practitioner or medical organization providing follow-up care, treatment, or services
21RC.02.01.01
Current EP Text:
EP:
Revision Type:
The medical record of a patient who receives urgent or immediate care, treatment, and services contains all of the following: - The time and means of arrival - Indication that the patient left against medical advice, when applicable - Conclusions reached at the termination of care, treatment, and services, including the patient's final disposition, condition, and instructions given for follow-up care, treatment, and services - A copy of any information made available to the practitioner or medical organization providing follow-up care, treatment, or services
18RC.02.01.01
New EP Text:
EP:
Moved
The medical record contains the patient’s race and ethnicity.
28RC.02.01.01
Current EP Text:
EP:
Revision Type:
The medical record contains the patient’s race and ethnicity.
25RC.02.01.01
New EP Text:
EP:
Moved
Page 11 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
Hospital (HAP) Accreditation Program Issued January 17, 2018
For hospitals that elect The Joint Commission Primary Care Medical Home option: The medical record includes the patient’s self-management goals and the patient’s progress toward achieving those goals.
29RC.02.01.01
Current EP Text:
EP:
Revision Type:
For hospitals that elect The Joint Commission Primary Care Medical Home option: The medical record includes the patient’s self-management goals and the patient’s progress toward achieving those goals.
26RC.02.01.01
New EP Text:
EP:
Moved
Page 12 of 12 Prepublication Requirements
July 1, 2018 Standards Release © 2018 The Joint Commission
