Joint Commission Deletes More Than 130 Requirements, Including Medical Record Requirements

In a bold move, the Joint Commission deleted 131 requirements for the hospital program in late April. The deleted requirements include a number of documentation, privacy, and information continuity requirements.

Some of the deleted requirements were removed because they were duplicative of other requirements or implicit in other standards, the Joint Commission said. Others, however, will now be left up to the discretion of hospitals, such as IM.02.01.03, which requires hospitals to maintain the security and integrity of health information, and IM.02.02.01, which requires hospitals to effectively manage the collection of health information. Other privacy or information integrity laws, such as HIPAA, will still apply.

Other deleted documentation requirements include:

• PC.04.01.05—The hospital provides written discharge instructions in a manner that the patient and/or the patient’s family or caregiver can understand (Deleted: duplicative of RI.01.01.03, EP 1)
• RC.01.01.01—The medical record contains information unique to the patient, which is used for patient identification (Deleted: duplicative of RC.02.01.01, EPs 1 and 2); The hospital assembles or makes available in a summary in the medical record all information required to provide patient care, treatment, and services (Deleted: part of regular operations/processes that should be determined by the organization)
• RC.01.04.01—The hospital measures its medical record delinquency rate at regular intervals, but no less than every three months (Deleted: part of regular operations/process that should be left to the discretion of the organization)
• RI.01.03.03—The hospital honors the patient’s right to give or withhold informed consent to produce or use recordings, films, or other images of the patient for purposes other than his or her care (Deleted: process issue that should be left to the discretion of the organization)

Additional deleted requirements relate to safety and environment standards, infection control, staff training and competency, business ethics and management, and protection of patient rights during research or investigations. Hospitals should carefully review all deleted requirements and ensure they continue to comply with other laws and regulations that still apply.

The revised standards will be effective July 1.