Milestone One PDF

Preview

Summary

Milestone One...

Description

Luna 1

Analysis of Health Record and Joint Commission Hilary Luna Southern New Hampshire University New England North Hospital Health Record Review

Luna 2

Analysis of Health Record and the Joint Commission Accurate and complete health records are key to the quality of patient care and safety in any healthcare facility. According to our Textbook Health Information Management by Oachs and Watters (2020, pp.102), the process of documentation and maintenance of patient information has been standardized by the Joint Commission (TJC), and each healthcare facility must comply with these standards in order to be accredited. As a health information consultant for New England North Hospital, I am responsible for ensuring compliance with The Joint Commission standards of Record of Care regarding the required data needed for a complete health record. As I review the patient record of Pam Ray, I will report my findings related to the compliance with the laws, rules, and regulations regarding the documentation of health records. By looking at the Health and Physical Examination, has no known family history of diabetes, heart disease or tuberculosis. Ms. Ray underwent an extraction of 6 mandibular teeth and a mandibular alveolectomy. These procedures will be performed by Dr. Harold Dunn. A general anesthesia and Xylocaine infiltration anesthesia was used during these procedures. The Medication Administration Record shows that Ms. Ray is to take Tylenol with codeine four times a day as needed. The standards of Record of Care (RC) are routinely reviewed by the Joint Commission to ensure all required information is documented correctly. According to the Joint Commission Edition, hospitals must maintain complete and accurate medical records for each individual patient. All entries in the medical record must also be authenticated and entered in a timely manner. The Joint Commission checks to see if the hospital conducts ongoing evaluations of their records and if original or legally reproduced forms of health records are retained by the

Luna 3

hospital. Each patient medical record must contain information that reflects the patient's care, treatment, and services, and any documentation on operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia. The standards state that all qualified medical staff authorized to receive and record verbal orders, must be identified and confirmed as the only persons receiving and recording these orders. A patient’s health record must also contain discharge information, which includes a summary of the patient’s stay, treatment, and medication provided. After viewing Pam Ray’s health record, there were parts of the record that were correctly documented. The patient’s correct age was listed on the face sheet and the consent for treatment form was signed. The anesthesia that was used on Ms. Ray during her procedures were also listed. I have noticed that there are sections of the record that are missing documentation. The Health and Physical Examination section of the health record is missing the patient’s date of birth on the last page and the admitting diagnosis was not recorded. Insurance/billing information was also not listed on the face sheet. The discharge summary of the patient was not signed by the physician nor was the information given about activity, diet, and goals/progress. Using the Joint Commission E-dition webpage (2020), I have found that New England North Hospital has an outstanding number of health record errors that could potentially be problematic for this facility. The wrong patient’s name was listed in the record and the date of birth was missing in the Health and Physical Examination. This violates the standard RC.02.01.01, which reflects the patient’s care, treatment, and services received at the facility. Having the correct demographic information for the patient is critical because errors can be made if the wrong patient is identified. RC.02.01.01 was also violated when the past medical history, signature for consent, and completed insurance information was not provided (TJC E-dition,

Luna 4

2020). Health care professionals need to know past medical history so they can provide the most efficient care for that patient. The signature is needed so the hospital knows that patient understand what type of treatment they are receiving and ensures the medical staff will not perform any procedures the patient does not agree to. Legibility in health records is extremely important because the healthcare team needs to be able to effectively communicate in order to provide proper care to the patient. The progress note from 4/18 is in a very small font that could be difficult for other medical staff to read correctly. This violates the TJC standard RC.01.04.01 reflecting how the facility audits their own records and elements of performance, which includes the legibility of their notes, hand-written or typed (TJC E-dition, 2020). Signatures were missing form the physician on the fact sheet, the last progress notes from 4/18, and the discharge summary. This violates the standard RC.01.02.01 regarding the authentication of the medical record (TJC E-dition, 2020). This standard is important to make sure the physician caring is authorizing the care the patient is receiving and making sure if it accurate. The date and time must be on every page of the health record, but the progress note from 4/19, regarding the patient’s podiatry: recovering from an infected ingrown toenail, was not stamped with a date or time. The discharge summary also did not have a time stamp, which violates the TJC standard RC.01.01.01, requiring the health record must maintain complete and accurate information (TJC E-dition, 2020). This standard is required because the facility needs to be able to know what time any action has been taken to care for the patient so they can avoid giving inaccurate care. The discharge summary was not signed nor did it provide any information about the patient’s activity, diet, and progress/goals for the patient after discharge. The TJC standard RC.02.04.01 requires the health record to include discharge information regarding the patient’s care after the stay at the

Luna 5

facility. The patient needs to know what kind of restrictions they have as far as physical activity, diet, and any rehabilitation they need to get once they are out of the healthcare facility. From looking at the healthcare record of Pam Ray, New England North Hospital HIM department has some serious work to do in order to bring them up to standard complying with the Joint Commission guidelines. The HIM professionals need to sure all of the information that is required is provided in the record. The patient’s name, date of birth, insurance, medical history and consent are all necessary for the health care professionals to efficiently care for their patient. Leaving legible notes and double checking for authorizing signatures are important for effective healthcare staff communication. Complete discharge summaries help the patient receive quality care from the hospital’s healthcare staff. I suggest that the New England North Hospital is given a temporary accreditation on a probationary basis, in order for the HIM team to fix any and all discrepancies with all other medical records. A follow-up evaluation of the facility’s health record will be performed to make certain that New England North Hospital has followed the recommended changes to their health record documentation procedures and are in compliance with the Joint Commission standards for accreditation.

Luna 6

References Oachs, Pamela K. & Watters, Amy L. (2020). Health Information Management: Concepts, Principles, and Practice. Chicago: IL: AHIMA Press. The Joint Commission E-dition. (2020). Accreditation: Record of Care, Treatment, and Services. Retrieved from https://e-dition.jcrinc.com/MainContent.aspx...