Health Information Management Essay

The following academic paper highlights the up-to-date issues and questions of Health Information Management Essay. This sample provides just some ideas on how this topic can be analyzed and discussed.

The following pages will provide a summary of the current compliance status of Nightingale Community Hospital based on the Information Management Priority Focus Area. From the information provided by Nightingale Community Hospital [the hospital] or readily available to the audit team, many Joint Commission standards are not currently being met and will require corrective action prior to an audit to ensure success.

The next Joint Commission visit is anticipated in 13-months, and the hospital should focus on fixing these areas before then.

These three standards include multiple Elements of Performance [EPs] that the hospital should be sure are implemented within policies or procedures that are able to be referenced by the Joint Commission. These standards were chosen by the hospital as the items to be internally pre-audited because it is understood that these are key issues in the proper operation of the hospital and protection of the patient’s data: 1) IM.

02. 02. 02 – This standard ensures the hospital is effectively managing the collection of health information.

This standard was chosen for this section because this is the very start of the hospital’s responsibility to maintain accurate and secure information for a patient. The process of Information Management starts with this standard being met. 2) RC. 01. 01. 01 – This standard ensure the hospital maintains complete and accurate medical records for each patient. This standard carries over importance from the previous mentioned standard.

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This ties into Information Management for the hospital because after the data is collected, the hospital must maintain it properly to be within compliance and protect their patients’ information.

Health Information Management Essay

3) RC. 01. 04. 01 – This standard ensures hospitals audit their medical records. This also follows the same trend as the first two standards chosen, because in order to properly manage the information, periodic audits must be taken to confirm previous policies and procedures are not only being followed by staff, but are working in the hospital’s favor by meeting compliance and hospital standards. Page 1 of 5 Standard Label & Text (The Joint Commission, 2012) IM. 02. 02. 01 The hospital effectively manages the collection of health information.

Current Compliance Status of Nightingale Community Hospital: Information Management Elements of Performance Does Nightingale Have a Corrective Plan of Action (EP) Corresponding Policy or (if applicable) Procedure to Address the EP? 1) The hospital uses uniform data sets to standardize data collection throughout the hospital. 2) The hospital uses standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations.

3) The hospital follows its list of prohibited abbreviations, acronyms, symbols, and dose designations, which includes the following: U,u; IU; Q.D. , QD, q. d. , qod; Trailing zero (x. 0 mg); Lack of leading zero (. X mg); MS; MSO4; MgSO4. 1) The hospital defines the components of a complete medical record.

4) The medical record contains information unique to the patient, which is used for patient identification. 5) The medical record contains the information needed to support the patient’s diagnosis and condition. Yes; The Admission Order form allows for collection of standardized information. Yes; Both the Admissions Order form and the “Prohibited Abbreviations” Patient Care Policy follow standardized criteria.

Yes; The Patient Care Policy “Prohibited Abbreviations” provides the list of prohibited abbreviations and reasoning behind not using them. Ensure all other forms other than the Admissions Order form also are using the same standardized criteria as indicated in the EP. Ensure all other forms other than the Admissions Order form also are using the same standardized criteria as indicated in the EP. None at this time – Policy is already in existence and compliant. RC. 01. 01. 01 The hospital maintains complete and accurate medical records for each individual patient.

No; The hospital did not provide a components list for a complete medical record. No; The Admissions Order form only indicates the patient’s name only. No; The Admissions Order form does not prompts for diagnosis or condition, only action items. Develop, or provide for review, an index summary to include all components of a complete medical record. Add multiple (at least two) forms of patient identification to the medical record (listed on all documents) such as patient ID, DOB, or address.

Add, or provide for review, a diagnosis or condition section and description component to medical record. Page 2 of 5 Standard Label & Text (The Joint Commission, 2012) RC. 01. 01. 01 (Cont’d) The hospital maintains complete and accurate medical records for each individual patient. Elements of Performance (EP) Does Nightingale Have a Corresponding Policy or Procedure to Address the EP? No; The Admissions Order form does not prompt for justification for treatment orders. Corrective Plan of Action (if applicable).

6) The medical record contains the information needed to justify the patient’s care, treatment, and services. 7) The medical record contains information that documents the course and result of the patient’s care, treatment, and services. 8) The medical record contains information about the patient’s care, treatment, and services that promotes continuity of care among providers. Add, or provide for review, a justification/comments block for each component within medical record. No; The Admissions Order form does not have a section to track patients care, treatment or services.

No; The Admissions Order form includes a checkbox for a courtesy call to primary care physician, but there is no description of care, treatment or services to track patients care or promote continuity of care. Yes; The Admission Order form allows for collection of standardized information. Yes; The Admissions Order form prompts for date and time. No; The hospital did not provide a document used to track the location of all components of the medical record. Add, or provide for review, a timeline section to be used for tracking care, treatment, services and/or results of patient within medical record.

Add, or provide for review a timeline section to be used for tracking care, treatment, or services and description of results of patient; also add provider comments section – this will ensure multiple providers will be able to provide accurate care, treatment or services. Ensure all other forms other than the Admissions Order form also are using the same standardized criteria as indicated in the EP. Ensure all other forms other than the Admissions Order form also require an accurate date record.

Add an index to the medical record including all sections to be included and prompt for their current location (within the record). 9) The hospital uses standardized formats to document the care, treatment, and services it provides to patients. 11) All entries in the medical record are dated. 12) The hospital tracks the location of all components of the medical record. Page 3 of 5 Standard Label & Text (The Joint Commission, 2012) RC. 01. 01. 01 (Cont’d) The hospital maintains complete and accurate medical records for each individual patient. Elements of Performance (EP).

Does Nightingale Have a Corresponding Policy or Procedure to Address the EP? Yes; The Admissions Order form prompts for a summary of all required care, treatment, or services. Corrective Plan of Action (if applicable) RC. 01. 04. 01 The hospital audits its medical records. 13) The hospital assembles or makes available in a summary in the medical record all information required to provide patient care, treatment, and services 19) For hospitals that use Joint Commission accreditation for deemed status purposes: All entries in the medical record, including all orders, are timed.

1) The hospital conducts an ongoing review of medical records at the point of care, based on the following indicators: presence, timeliness, legibility (whether handwritten or printed), accuracy, authentication, and completeness of data and information. 2) The hospital measures its medical record delinquency rate at regular intervals, but no less than every three months. None at this time – Form is already in existence and compliant. Yes; The Admissions Order form prompts for date and time.

Ensure all other forms other than the Admissions Order form also require an accurate date record. No; the hospital did not provide information on their accuracy checks. Ensure medical records are being updated and checked at point of care as indicated in EP. No; Hospital’s records have been measured by year time periods only. Must break-out and measure delinquency rates no less than every three months as indicated in EP. If possible, re-run data to formulate 3 month timeframe reporting. On an ongoing basis, create a new Policy and Procedure to manage the three-month cycle reporting.

Provide historical quality measurements and use the Hospital Medical Record Statistics Form to confirm the average rate is 50% or less. 4) The medical record delinquency rate averaged from the last four quarterly measurements is 50% or less of the average monthly discharge (AMD) rate. Each individual quarterly measurement is no greater than 50% of the AMD rate No; the hospital did not provide historical quality measurements. Page 4 of 5 References The Joint Commission. (2012). Accreditation requirements. Retrieved 09 25, 2012, from The joint commision e-dition: https://e-dition. jcrinc. com/MainContent. aspx.