JCAHO Requirements for Charting on Nursing Care Plans

The Joint Commission on Accreditation of Healthcare Organizations is a private non-profit organization which sets a standard for healthcare facilities and providers. While facilities are not required to have JCAHO certification, it has become an industry standard which few hospitals want to be without. JCAHO monitors many aspects of a hospitals operation from billing to key aspects of patient care. JCAHO gives considerable latitude to facilities in their plan of care charting, but has certain areas of concern and oversight.

Prohibited Abbreviations

• One clear JCAHO mandate is that certain abbreviations are not allowed. The organization publishes a list of prohibited abbreviations in its manual. Hospitals should review this list with nurses to ensure compliance. Examples of blacklisted abbreviations include U for Unit and IU for International Unit because these can easily be mistaken for other abbreviations or read incorrectly. A poorly formed IU resembles IV and might lead to an improperly administered intravenous medication. The manual also forbids the use of QD to mean every day and QDD to mean every other day. These abbreviations are also easily confused.

Clarity

• JCAHO cares that information is properly, accurate transmitted from one professional to the next. Charting is critical to a patient's care and safety. Therefore, it must be done so that the nurse or doctor who reviews the chart can understand what it means. While JCAHO leaves it up to facilities and clinicians to figure out how to do this, the nurses who perform JCAHO audits expect to understand the notes of the charts they review at random.

  Of course all plans of care should be interested in patient safety, appropriate treatment and timely responses to patient incidences. JCAHO has extensive standards on how care is given and charts should reflect those as well.

Medicare Standards

• One of JCAHO's roles is to check for Medicare compliance. Care plans must be appropriate to the patient's condition and show quality nursing thought. Charting should be done so that both a JCAHO reviewer and a Medicare reviewer can understand. Patient goals, reasons for the goals and measurable steps aimed at progress are all necessary components for Medicare reimbursement. Plans of care should make sense to Medicare reviewers who have had less medical training than the nurse. JCAHO auditors will review charts from this perspective.