by Stephen T. Olin, MD
Lancaster General Health underwent its unannounced tri-annual TJC (Joint Commission) survey August 10-14, 2009; the survey team, as during previous surveys, was extremely impressed with the staff, their commitment to patient care in providing and extraordinary experience, their focus on patient safety and performance improvement, and the vibrant atmosphere of our physical environment and state-of-the-art technology.
Non-compliant standards directly related to the Medical & Dental staff included:
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Clinical entries not dated and timed.
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Verbal orders not signed, date, and timed within twenty-four hours.
The following represent “marching orders” for all members of the Medical and Dental Staff:
Medical Record Entries
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All entries in the medical record must be dated, TIMED, and authenticated by the person responsible for providing or evaluating the service provided.
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Applies to ALL entries. Examples include:
- Physician orders
- Progress notes
- Post-procedure notes
- Code-signature of verbal orders
- H&P’s and Updates to H&P’s
Verbal and Telephone Orders
- Verbal and Telephone Orders must be:
- Countersigned by a practitioner within twenty-four hours of giving the order.
- Dated and timed.
We are required to submit a corrective action plan to the Joint Commission to address this deficiency. We must demonstrate 90% compliance with the standards on a random survey of charts four months following the Joint Commission’s acceptance of our action steps.
As our HER (EPIC) on the inpatient side will not be in place, the Medical & Dental Staff, as well as all others placing entries into the medical record will be challenged to meet this level of compliance. Thus, you will be seeing prominent reminders throughout all clinical settings reminding clinicians to time, date, and sign ALL entries placed in the medical record.
Please work with your nursing colleagues to ensure that we are compliant with this Joint Commission (and Department of Health) standard.
As all aspects of our lives are affected by time, remember that:
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A stitch in time saves nine.
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Time and tide wait for none.
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Tempus Fugit
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It was the best of times, it was the worst of times…
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The times they are a-changing.
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Time is on my side, yes it is.
Therefore, please keep time on your side, as from henceforth when making rounds, please remember that “It’s Time to Sign.”