Surveyors will focus on findings from staff interviews and observations to score these standards. In this case, it is important for all staff, including physicians, to understand the standards, along with the organization's related policies and procedures. These medical record standards are all too familiar, but they continue to wreak havoc at the time of surveys. Surveyors will be looking for a postoperative progress note to be written in the medical record immediately after surgery for inpatients and outpatients. Surveyors will be looking for signatures on operative reports, because standard IM.7.3.2.1 requires immediate authentication of the completed operative report.
Verbal orders continue to be a challenge for almost all organizations.
Any other authentication requirements will be surveyed according to state and organization policies. Questions have arisen as to whether dictated history and physical reports need to be authenticated within 24 hours in order to be complete. The Joint Commission recently published a clarification that indicates that a history and physical must be performed and documented within 24 hours, but authentication is based on organizational policy. This is very good news, because in many cases the history and physical is not signed until after discharge as part of the delinquent process. Remember, if this is an organization's policy, the history and physical must be signed within 30 days of discharge.