The Role of The Joint Commission
The Joint Commission is an accrediting body that evaluates healthcare organizations against defined standards, and accreditation can confer deemed status, satisfying Medicare Conditions of Participation requirements without a separate CMS survey. RHIA candidates should understand the categories of Joint Commission standards most relevant to health information practice.
Information Management Standards
- Continuity and availability of health information across the care continuum
- Protection of records from loss, damage, tampering, and unauthorized access
- Standardized abbreviations and prohibition of dangerous abbreviations
- Timely completion of medical records after discharge
These standards drive many operational HIM policies, including the do-not-use abbreviation list and record completion tracking systems.
Record Content Requirements
The Joint Commission requires that a complete medical record contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course of care, and promote continuity of care among providers. HIM departments audit records against these criteria to identify deficiencies before survey.
Tracer Methodology
During onsite surveys, Joint Commission surveyors use a tracer methodology, following an individual patient's experience through the organization to evaluate compliance across departments, including health information handoffs, documentation timeliness, and information availability at the point of care.
National Patient Safety Goals
Several National Patient Safety Goals intersect with health information practice, such as accurate patient identification using two identifiers and improving the effectiveness of communication among caregivers, which relies heavily on complete and legible documentation.
Preparing for Survey
HIM leaders often conduct mock tracers and ongoing record audits to maintain survey readiness year-round rather than only before a scheduled survey window, since Joint Commission surveys are unannounced.
Exam Tips
Expect questions distinguishing Joint Commission standards from CMS Conditions of Participation, understanding the concept of deemed status, and identifying HIM's responsibilities in maintaining ongoing survey readiness through ongoing performance improvement activities related to record completeness and accuracy.