Scenario: You are the HIM Director at Sacred Heart Hospital. After completing a documentation audit, you have identified three significant issues that you believe do not align with Joint Commission requirements:
History and physical examinations (H&Ps) are not complete (missing chief complaint and review of systems) and are not being done within the required time frame following admission.
Discharge summaries are not complete (missing elements or lack detail) and are not being done promptly upon discharge.
Progress notes are brief, use prohibited abbreviations, and do not describe patient’s condition, including improvement or decline.
You must now create an action plan to correct these issues and improve documentation. You will also conduct a focused audit of three additional charts.
Answer the following questions and submit as a word document or pdf. See the rubric for detailed grading information.
List the JC standard(s) relevant to each of the three identified issues. Include the Standard Label, Standard Text, and the specific Elements of Performance that apply. You must also briefly explain why you think these standards apply.
You may copy and paste the JC standard information, but make sure to strip out all formatting/links. For the Elements of Performance, you only need to copy/paste the relevant portions of text. See the example below.
Create an action plan that answers the following questions:
Which issue(s) would you prioritize and why?
What specific steps would you take to address these three identified issues?
Who would you involve (i.e., physicians, other providers, admin, HIM, etc.) and why?
What type of follow-up would be needed? When/how often would the follow-up occur?
Select three charts (different from the one you selected for the Chart Review project) from the Example Medical Records module (located at bottom of the Modules page). Conduct a focused audit on the three identified issues (H&P, d/c summary, progress notes) and share your findings in a narrative format. Make sure to include the chart IDs (use file name – if I cannot tell what charts you are discussing, you will receive a zero for this question!).
Example for Question #1
Identified Issue: Providers are sharing signature stamps.
JC Standard:
RC.01.02.01 Entries in the medical record are authenticated.
EP 4 Entries in the medical record are authenticated by the author.
EP 5 The individual identified by the signature stamp or method of electronic authentication is the only individual who uses it.
I think that these apply because EP5 states only the individual can use their signature stamp, which sharing clearly violates. Also, EP4 states that the author must authenticate their entry, and if they are sharing signature stamps, authorship/authentication is put into question.
Scenario: You are the HIM Director at Sacred Heart Hospital. You have been asked to report on the authentication of the medical record at the next Quality Improvement meeting. To prepare for your presentation, you conduct an audit of a sampling of records and uncover some glaring issues.
1. Physician verbal orders and progress notes are not consistently dated, timed, and authenticated.
2. Some nurse practitioners without privileges are documenting in the medical records on behalf of their physician employers.
3. There is a large backlog of discharge summaries, so a project was initiated in which nurses are paid to dictate summaries to clear the backlog. The summaries are signed by the Medical Director.
4. Finally, while this was not discovered in the audit, you recall rumors that clinical staff often share credentials.
Directions:
Download and complete the provided template Download template . For each issue, you need to identify and summarize relevant Joint Commission standards (using the eDition) https://edition.jcrinc.com/ProxyLogin.aspx?lnk=f0475d880a4c&PID=2
E-dition – Standards & EPs (jcrinc.com) and identify the responsible party/parties that will be in charge of ensuring each standard is followed.
1. JC Chapter and Standards
· Issues may have more than one relevant standard. Your standards must be drawn from at least three different chapters (for example, you cannot solely use the Medical Staff chapter or the Record of Care, Treatment, and Services chapter for all four issues). Make sure to include the full chapter name, the standard number, and the standard text. Example: Information Management – IM.01.01.01 The hospital plans for managing information.
2. Summary of Standard and EP
· You need to summarize the standard and relevant EPs in your own words. Remember that this is for a report – your summary should be professional, concise, and clear. You may use a maximum of two direct quotes (1-2 sentences each). Direct quotes need to be cited in APA format. Copy/pasting from the EPs without a citation is considered plagiarism.
3. Responsible Party
· Identify a responsible party or parties for each standard (remember, HIM does not create the Medical Staff Rules and Regulations, but we are often tasked with enforcing them!).
4. Example for Question #1
5. Identified Issue: Providers are sharing signature stamps.
6. JC Standard: RC.01.02.01 Entries in the medical record are authenticated. EP 4 Entries in the medical record are authenticated by the author. EP 5 The individual identified by the signature stamp or method of electronic authentication is the only individual who uses it. I think that these apply because EP5 states only the individual can use their signature stamp, which sharing clearly violates. Also, EP4 states that the author must authenticate their entry, and if they are sharing signature stamps, authorship/authentication is put into question.
,
Issue
JC Chapter and Standard
Summary of Standard & EP
Responsible Party
Physician verbal orders and progress notes are not consistently dated, timed, and authenticated.
Some nurse practitioners without privileges are documenting in the medical records on behalf of their physician employers.
Nurses are dictating missing discharge summaries to be signed by the Medical Director.
There are rumors that staff are sharing credentials.
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