Sure-Fire MethodS

Complying with RC.01.01.01 for

Behavioral Health Care

T

he clinical/case record functions not only as

a historical record of an individual’s episode(s) of care, but also as a method of communication among staff that can aid in making decisions about care, treatment, or services. Joint

Commission Record of Care, Treatment, and Services (RC) Standard RC.01.01.01 requires that organizations

maintain complete and

accurate clinical/case records (see “Related Requirements” on page 3 for the entire standard). Recent Joint Commission statistics show

Inaccurate or incomplete clinical records can put

patient safety at risk.

that during the first half of 2014, standard RC.01.01.01 was one of the 10 most challenging standards for behavioral health care organizations, with 12% of surveyed organizations found to be noncompliant.

According to Merlin Wessels, LCSW, associate director, Standards Interpretation Group, The Joint Commission, Element of Performance (EP) 11 is one that is frequently cited because chart entries are not dated. “You need to document when things actually occurred,” he says. “In certain situations, entries also need to include times. For example, restraint and seclusion orders are time limited, so start and stop times have to be documented.”

Another reason why organizations are struggling to comply with Standard RI.01.01.01 is that documentation is not being done in a timely fashion. “Documentation is sometimes not done within the time frame identified by the organization, so the next person providing care may not have all the relevant information,” says Wessels.

The use of multiple formats for documentation can also be problematic. “In some cases, when new documentation forms are developed or old forms are

revised, some staff continue to use the old forms while others are using the new,” Wessels says.

Another reason why organizations are being cited for noncompliance with Standard RI.1.01.01 is that the clinical/case records do not contain the

information needed to justify the care, treatment, or services provided, as required by EP 6. “You need some type of documentation that services were actually

Related Requirements

Standard RC.01.01.01

The organization maintains complete and accurate clinical/ case records.

Elements of Performance for RC.01.01.01

1. The organization defines the components of a complete

clinical/case record.

1. The clinical/case record contains information unique to the individual served, which is used for identification of the individual.

2. The clinical/case record contains the information needed to support the diagnosis or condition of the individual served.

3. The clinical/case record contains the information needed to justify the care, treatment, or services provided to the individual served.

   
   

4. The clinical/case record contains information that documents the course and result of the care, treatment, or services provided to the individual served.

5. The clinical/case record contains information about the care, treatment, or services provided to the individual served that promotes continuity of care among providers.

6. The organization uses standardized formats to document the care, treatment, or services it provides to individuals served.

11. All entries in the clinical/case record are dated.

1. The organization tracks the location of all components of

   the clinical/case record.

2. The organization assembles or makes available in a summary in the clinical/case record all information required to provide care, treatment, or services to the individual. (See also MM.01.01.01, EP 1)

provided,” says Wessels. “When looking at an individual’s record, the surveyor should be able to follow the course of care by reading the documentation.”

Wessels offers the following five strategies to help organizations to better comply with Standard RC.01.01.01:

1

Identify what needs to be documented and how it can be done most efficiently. “Documentation takes

time,” Wessels says. “Developing a streamlined process will make documentation easier, which will allow staff to spend more time providing services.” (See the tool in Figure 1, below.)

2

Conduct periodic chart audits. “If information is missing, do something to remedy that,” says Wessels. “If some people are more prone to

(continued on page 15)

Figure 1. Clinical/Case Record Compliance Assessment Checklist

Use the checklist below to determine whether your clinical/case records contain all the necessary elements to comply with

RC.01.01.01.

5 Sure-Fire Methods

(continued from page 3)

incomplete documentation, you may need to reeducate them or even take administrative action if the problem persists.”

3

Make sure everyone is using the same documentation forms. “When new forms are implemented, get rid of the old ones,” Wessels says. “Make sure staff doesn’t have any of the old forms stashed in their desks.”

4

Include a place for the date and time on documentation forms. “Whether you’re using paper records or electronic, there should be a section that asks for the date and time,” says Wessels. “If you’re using electronic records, you can put in hard stops so that staff can’t continue until those sections are filled out.”

5

Develop standardized documentation forms. “Standardized forms let everyone know what documentation is required so they don’t have to rely on memory,” Wessels says. “It also helps when you’re doing audits because everything is all on one form, so you don’t have to look for information buried in the chart.” TS