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Identification of Documentation Gaps and Compliance Rate using Joint Commission International Standards at one of the Leading Hospital in Coimbatore

Mr. Sukanth.K1, Ms. Yagavi Preetham2
1Assitant Professor, Department of Hospital Administration, Dr.N.G.P. Arts and Science College
2Student, Department of Hospital Administration, Dr.N.G.P. Arts and Science College

Abstract
Healthcare documentation plays a crucial role in ensuring quality patient care, effective communication among healthcare professionals, and compliance with accreditation standards. International accreditation bodies such as Joint Commission International (JCI) emphasize accurate and structured documentation to support patient safety and quality improvement initiatives. The purpose of this study was to identify documentation gaps and determine the compliance rate with selected patient-centered standards of JCI. A cross-sectional audit design was used to evaluate documentation practices related to seven patient-centered chapters: Access to Care and Continuity of Care (ACC), Assessment of Patients (AOP), Care of Patients (COP), Anaesthesia and Surgical Care (ASC), Medication Management and Use(MMU), International Patient Safety Goals (IPSG), and Patient-Centered Care (PCC). A structured checklist based on JCI measurable elements was used to review a total of 149 documents, including policies, standard operating  procedures, forms, audit records, and staff training records. Descriptive statistical analysis was applied to calculate compliance levels across the chapters. The results revealed an overall documentation compliance rate of 93.28%, indicating strong adherence to international documentation standards. However, minor gaps were identified in areas such as patient assessment documentation, medication management records, and patient safety documentation. The findings highlight the importance of regular monitoring, staff training, standardized documentation templates, andelectronic documentation systems to maintain consistent compliance with accreditation standards. Strengthening documentation practices not only supports accreditation readiness but also improves patient safety, communication, and healthcare quality.
Keywords: Healthcare Documentation, Joint Commission International, Documentation Compliance, Patient Safety, Accreditation Standards, Quality Management.