What Are JCAHO Requirements for Dictation?

JCAHO stands for Joint Commission on Accreditation of Healthcare Organizations, known commonly as the Joint Commission. It is an independent agency that certifies the performance standards of healthcare programs. The organization provides guidelines on dictation.

Office Based Surgery

Office based surgery is a surgical procedure that requires anesthesia and that is performed in an office setting by a licensed physician. The Commission defers to state laws or organizational policy to determine the time frame in which dictation must be transcribed and placed in medical records. At minimum, immediately after the surgical procedure, a handwritten progress note that details enough information to manage a patient through the postoperative period must be placed in the medical record.

Acute Care

In an acute care medical settings, the average length of stay for patients is thirty days or less. JCAHO defers to organizational policies in determining the time frame for placing dictated and transcribed materials in medical record. However, at minimum a handwritten note by a licensed independent practitioner must be placed in the medical record within 24 hours of admission.

Long Term Care

The average length of stay in a long term care setting is greater than 25 days. The commission allows organizational policy to dictate the time frame in which dictations should be transcribed and placed into medical records. There is a prevision, however, that mandates that within 72 hours a licensed independent practitioner must handwrite a note that provides enough information for clinicians to manage a patient's care.

References

• The Joint Commission
• Boston Scientific: State Regulatory Environment Overview: Office-Based Surgery
• The Joint Commission: Operative Reports
• American Hospital Association: Subcommittee on Acute Care: Background Paper
• The Joint Commission: Authentication of the H&P in 24 Hours
• The Joint Commission: Authentication of H&P in 72 hours