How to Identify Some Specific Documentation Standards of JCAHO

The Joint Commission --- formerly and still popularly known as the Joint Commission on Accreditation of Healthcare Organizations --- sets standards for how medical facilities and home health agencies should run. The private nonprofit group has no authority to mandate facilities to run by Joint Commission standards; however, JCAHO accreditation is something no hospital wants to be without, as JCAHO is the industry benchmark. The Joint Commission is also authorized by the Center for Medicare and Medicaid Services to audit hospitals for Medicare compliance. The Joint Commission has copious standards for clinical documentation and record keeping, which all clinicians should know.

Instructions

• 1

  Use the resources offered by the Joint Commission. The Joint Commission produces a "Written Documentation Standards" manual you can request for free and which you can also download for free from the Joint Commission website. This provides you a list of standards across clinical disciplines. Additionally, the Joint Commissions has a Topic Library on its website from which you can download manuals addressing documentation standards within various clinical areas such as endoscopy, behavioral health and telemedicine.

• 2

  Study some Joint Commission documentation samples. Numerous organizations have chart and billing samples with detailed guides and explanation about how the samples meet or fall-short of Joint Commission requirements. This is a great way to better understand the application of specific standards. Contact organizations such as the American Health Information Management Association (AHIMA), the federal Agency for Healthcare Research and Quality, and the American Nurses Association for materials.

• 3

  Enroll in continuing education courses for your profession. Nurses, for example, can gain continuing education credits they need to maintain their licenses while receiving in-depth training on the latest changes and issues in Joint Commission documentation standards. A good course will have an instructor who walks you through sample cases and charts to identify common problems and how to bring documentation in line with standards.

• 4

  Talk to your supervisor or a workplace expert to get information on specific issues and questions you may have. Clinical supervisors are responsible for educating you about Joint Commission standards and how to achieve them. Additionally, many hospitals have Joint Commission coordinators and nurse educators whose jobs include making clinical staff aware of current Joint Commission documentation rules.