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Documentation Challenges When Providing Care While Operating Under an Emergency Operations Plan (BHC)

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

Any examples are for illustrative purposes only and is not intended to address every possible scenario.

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), the type, amount, frequency, format and location of such documentation is determined by the individual organization. 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.

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 as relevant to setting(s), services(s), programs(s) and specific population(s) in accordance with laws and regulations.

Consider the following:
  • Assessments and the frequency performed are determined by the needs of the individual patient and organizational policy. The organization determines the assessment/reassessment criteria. Such requirements would be an organizational decision. 
Similar to assessments, screenings (which can lead to more in-depth assessments) are completed based on the presenting complaint/diagnosis. For example:
  • Suicide risk:  All patients are to be screened for suicide risk using a validated screening tool and those screened positive are to be assessed using an evidence-based process.
  • Risk for harm: All patient are to be screened for risk for harm to self and others to determine a need for immediate intervention.
  • Trauma, abuse, neglect and exploitation: All patients need to be screened and assessed for trauma, abuse, neglect and exploitation.
  • 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. 
  • 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.
Organizations that use Joint Commission accreditation for Opioid Treatment Programs for deemed status purposes should monitor the SAMHSA website for any approved waivers. Click here to access the SAMHSA website. Organizations should also monitor respective state websites for any state-specific waivers.

Additional Resources:
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Last updated on July 26, 2021
Manual: Behavioral Health
Chapter: Care Treatment and Services CTS

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