Records Access - Access to Outside EHR
For the Advanced Certification in Spine Surgery program, would the program having access to the surgeon's office EMR to follow the patient's course and results of care after patient discharge, meet the requirements of DSCT 02.01.01, EP 1?
Any examples are for illustrative purposes only
Yes, this would still meet the requirements, as the program will still have a way to access the medical record documents. The program would be expected to access these medical record documents during review activities.
DSCT 02.01.01, EP 1 states that "The medical record contains complete and accurate documentation of the disease-specific care, treatment, and services provided." Specific to spine surgery under "c" it states, "Information in the medical record includes spine surgeon's office notes, lab results, x-ray reports, and post-discharge documents."
The Joint Commission does not specify what is to be included in the "post-discharge documents", this is determined by the organization. It is important, however, that at an organizational level, what is included in the post-discharge documents is standardized to decrease variability in care and the record reflects the care provided and the surgical outcomes. The prehospital/surgical center and post hospital/surgical center care is a distinguishing factor between the Advanced program and the Core program.
Yes, this would still meet the requirements, as the program will still have a way to access the medical record documents. The program would be expected to access these medical record documents during review activities.
DSCT 02.01.01, EP 1 states that "The medical record contains complete and accurate documentation of the disease-specific care, treatment, and services provided." Specific to spine surgery under "c" it states, "Information in the medical record includes spine surgeon's office notes, lab results, x-ray reports, and post-discharge documents."
The Joint Commission does not specify what is to be included in the "post-discharge documents", this is determined by the organization. It is important, however, that at an organizational level, what is included in the post-discharge documents is standardized to decrease variability in care and the record reflects the care provided and the surgical outcomes. The prehospital/surgical center and post hospital/surgical center care is a distinguishing factor between the Advanced program and the Core program.
Manual:
Advanced DSC - Spine Surgery
Chapter:
Clinical Information Management DSCT
This page was last updated on January 28, 2025