9. The Joint Commission Requirements for IPV Assessments and Documentation

An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 19,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

The Joint Commission requires accredited hospitals to have systems in place to assess for IPV with patients and document findings in patients’ records using proper safeguards regarding confidentiality.

The Joint Commission’s standard and intent related to IPV assessments with patients is:

Standard PE.1.8

Possible victimes of abuse are identified using criteria developed by the hospital.

Intent of PE.1.8

Victims of abuse or neglect may come to a hospital through a variety of channels. The patient may be unable or reluctant to speak of the abuse, and it may not be obvious to the casual observer. Nevertheless, hospital staff members need to know if a patient has been abused, as well as the extent and circumstances of the abuse, to give the patient appropriate care. The hospital has objective criteria for identifying and assessing possible victims of abuse and neglect, and they are used throughout the organization. Staff are to be trained in the use of these criteria.

The Joint Commission's standard and intent related to IPV documentation is:

Standard PE.8

Patients who are possible victims of alleged or suspected abuse or neglect have special needs relative to the assessment process.

Intent PE.8

As part of the initial screening and assessment process, information and evidentiary material(s) may be collected that could be used in future actions as part of the legal process. The hospital has specific and unique responsibilities for safeguarding such material(s). Policies and procedures define the hospital's responsibility for collecting, retaining, and safeguarding information and evidentiary material(s). Hospital policy defines these activities and specifies who is responsible for carrying them out.

PC.12

Criteria are used to identify possible vistims of abuse or neglect.

PC.12.1

Victims of alleged or suspected abuse or neglect are assessed with the consent of the patient, parent, or legal guardian, or as otherwise provided by law.

PC.12.2

Notification and release of information are provided to the proper authorities, as required by law.

PC.12.3

Victims of abuse are referred to private or public agencies that provide or arrange for evaluation and care.

Intent of PC.12 and PC.12.1 through PC.12.3

Unless possible victims of abuse are identified and assessed, they cannot receive appropriate care. Such patients have special assessment and care needs. Objective criteria are used to identify and assess possible victims of abuse and neglect, and staff are trained to apply the criteria. The practice has a procedure for collecting, retaining, and safeguarding information and evidentiary material(s). The practice maintains a current list of private and public community agencies that provide or arrange for care of abuse victims and makes appropriate referrals.

(Source: The Joint Commission at www.jointcommission.org)