JCI expects records that show care as it happened, with assessments, consent, notes, handovers, medication records, staff qualifications and quality data complete and timed across a six-month look-back. JCI tests them by tracing patients, so the record must tell the story without help.
Where documentation sits in the standards
Documentation runs through every chapter, and Management of Information (MOI) governs how the organisation manages it. Staff Qualifications and Education (SQE) governs the staff files. Both sit in the Health Care Organization Management Standards of the 8th edition.1 Surveyors look back six months for evidence.2
| Record | Chapter | What makes it hold up |
|---|---|---|
| Assessment | AOP | Complete, timed and signed |
| Consent | PCC | What was explained, in which language, and when |
| Clinical note | COP | Written at the time, with changes visible |
| Medication record | MMU | Checks before prescribing and administration |
| Handover and referral | ACC | Signed, timed and received |
| Staff file | SQE | Qualifications and training current |
| Access to records | MOI | Controlled by role, with a log |
- Audit a sample monthly. Ten records a month, scored against the table above.
- Fix the workflow. A missing field means the workflow allows it. Change the workflow.
- Keep six months live. Surveyors look back six months, so make that period instantly reachable.
- Control access. Role-based access and a log of who read what.
- Show the trend. Completeness over time, in the quality reports.
- Record type ______ Sample ______
- Complete ______ Timed ______ Signed ______
- Gaps found ______
- Workflow change ______ Owner ______
Questions
How far back do surveyors look?
Six months.
Do electronic records satisfy JCI?
JCI assesses how information is managed in any medium. Electronic records with access control and an audit trail make that easier to show.
Which chapter covers records?
Management of Information (MOI), with record content assessed throughout the patient-centred chapters.
Sources
- 1Joint Commission International, 2024JCI Accreditation Standards for Hospitals, 8th editionRead source
- 2Joint Commission International, 2026Accreditation processRead source
Written by the wai team from Joint Commission International guidance, checked on 15 October 2026. This is guidance, not legal advice. JCI does not endorse wai or any software.