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Documentation Challenges Under an Emergency Operations Plan


Robert Campbell, PharmD, director, clinical standards interpretation for hospital/ambulatory programs

Editor’s Note: This blog post is part of The Joint Commission’s daily communication on issues relevant to organizations managing the COVID-19 pandemic. The full list of FAQs is available here.

When an organization is operating under their Emergency Operations Plan (EOP), what patient care documentation and related processes are required by the standards?

The Joint Commission standards only define ‘when’ written documentation is required as evidence of compliance. Unless specifically required by the language of an Element of Performance (EP), individual organizations determine the documentation’s:

  • type
  • amount
  • frequency
  • format 
  • location 

Therefore, organizations may modify policy-driven documentation requirements and format, as needed, under emergency conditions when resources are limited.  For example, The Joint Commission does not prohibit use of the ‘charting by exception’ model. Such decisions are up to leadership. However, there may be some regulatory agencies that are more prescriptive that must be observed. 

The ‘Requiring Written Documentation (RWD)’ chapter of the accreditation manual lists those EPs which require some form of written documentation.  Note that compliance with a number of accreditation requirements is determined by the presence or absence of a ‘process’.  Documentation is but one of a number of ways an organization can demonstrate compliance when documentation is not specifically required by the EP.

For organizations that use Joint Commission accreditation for deemed status purposes, Centers for Medicare and Medicaid Services (CMS) requires that the medical record contain information to:

  • justify admission and continued care
  • support the diagnosis
  • describe the patient’s progress and response to medications and services

However, CMS has issued waivers relaxing some of the documentation requirements during the COVID-19 emergency. 

Assessments and Reassessment
Each organization defines the scope and content of screenings, assessments and reassessments and how such activities are documented in the medical record. During an emergency, documentation requirements – including timeliness of entries - may be modified to meet their capabilities and needs. When temporary modifications are made, entries should remain sufficient to ensure that safety, quality and continuity of care within and across disciplines is maintained.  

Assessments and the frequency performed are determined by the needs of the individual patient and organizational policy. The organization determines the assessment/reassessment criteria.

Similar to assessments, screenings (which can lead to more in-depth assessments) are completed based on the presenting complaint/diagnosis. For example:

  •  Suicide risk: CMS requires that patients presenting with symptoms of a behavioral nature are to be screened for suicide risk.  However, there is NO requirement that organizations conduct universal screening for suicide on 100% of all patients presenting for care. 
  •  Nutritional screening: Such screenings are performed to determine if nutritional deficits exist that may require a more in-depth assessment. If such a screening does not reveal a nutritional deficit, a more in-depth assessment is not required.
  • Learning Needs Assessment/Patient Education: Such assessments allow the organization to determine what education may be required so the patient/family can continue care following discharge.  Such assessments and education are processes, therefore, the organization determines what, if any, documentation is required. 
  • Nursing Plans of Care:  CMS has relaxed this requirement per the CMS 1135 waiver published March 30, 2020.
  • Medication administration:  Documentation of medication administration,  actions taken, and their outcomes is essential for planning and delivering future care of the patient. The organization determines how this information is entered into the medical record. Medication orders are to be written in a manner that provides adequate guidance for safe administration and aligns with the therapeutic goals.
  • Patient identification: When organizations use technology, such as barcoding, as part of the medication administration process, and such devices are in short supply, the organization determines alternate safe administration practices. There is no Joint Commission standard that specifically requires use of barcoding technology.

Accredited organizations can find additional information regarding the impact of the CMS 1135 blanket waivers and Joint Commission requirement extensions on their secure extranet site located under the ‘Resources and Tools' tab.

Organizations that use Joint Commission accreditation for deemed status purposes should monitor the CMS website as waivers are being approved frequently and may include state-specific waivers. Click here to access the CMS website.

Robert Campbell, PharmD, is director, clinical standards interpretation hospital/ambulatory Programs and director, medication management. Prior to these roles, he served as the pharmacist for Clinical Standards Interpretation in the Division of Healthcare Improvement at The Joint Commission. Campbell also surveys as a field representative for The Joint Commission in the Hospital Accreditation and Critical Access Hospital Accreditation Programs and is a reviewer in the Medication Compounding Certification Program. Prior to joining The Joint Commission, Campbell worked in health care organizations and held leadership positions with oversight responsibilities for performance improvement, accreditation readiness, risk management, infection control, medical staff services, as well as inpatient and outpatient pharmacy services.