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Documentation Challenges When Providing Care While Operating Under an Emergency Operations Plan.

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.

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.

For organizations that use Joint Commission accreditation for deemed status purposes, 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.  Consider the following:
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.

Additional Resources
Coronavirus (COVID-19) Guidance and Resources
Manual: Critical Access Hospital
Chapter: Provision of Care Treatment and Services PC
Last reviewed by Standards Interpretation: April 27, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: April 09, 2020 This Standards FAQ was first published on this date.
This page was last updated on April 27, 2022 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.

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