Health Information Director

Health Information Director

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Question: The activity You are the Health Information Director at the General Hospital, which has been accr…

The activity

You are the Health Information Director at the General Hospital, which has been accredited by The Joint Commission (TJC). You have been notified that surveyors are currently onsite and, as part of their survey process, are utilizing the tracer methodology. They will be evaluating the direct care of patients currently admitted to the hospital and will also need access to the hospital’s EHR.

One of the patients whose care and medical record the surveyors will be examining is Ella Myrick. This patient is currently an inpatient admission at your hospital and is being prepared for discharge.

General Hospital’s Vice President tasked you with auditing Ella Myrick’s chart utilizing TJC’s tracer methodology. She asked you to emulate a surveyor and identify services and departments that the patient has come in to contact with during her hospital stay thus far. This information will help identify which departments to prepare in advance. She also advised you to examine specific Elements of Performance for this patient as it pertains to medical record documentation and standards.

Utilizing the partial excerpt below regarding Record of Care, Treatment, and Services (RC) standard from The Joint Commission, and the chart of Ella Myrick in EHR Go, answer the questions below.

Standard RC.02.01.01 The medical record contains information that reflects the patients care, treatment, and services Element of Performance for RC.02.01.01 C 2. The medical record contains the following clinical information: R . The reason(s) for admission for care, treatment, and services . The patients initial diagnosis, diagnostic impression(s), or condition(s) Any findings of assessments and reassessments (See also PC.01.02.01, EPs 1 and 4; PC.03.01.03, EPs 1 and 8) Any allergies to medications patients medical history and physical examination patients course of care, treatment, and services . Any allergies to food Any conclusions or impressions drawn from the Any diagnoses or conditions established during the including complications and hospital-acquired Any consultation reports Any observations relevant to care, treatment, and services The patients response to care, treatment, and services -Any emergency care, treatment, and services provided to the patient before his or her arrival . Any progress notes All orders Any medications ordered or prescribed strength, dose, and route devices used, and rate of administration Any medications administered, including the Any access site for medication, administration Any adverse drug reactions Treatment goals, plan of care, and revisions to the plan of care (See also PC.01.03.01, EPs 1 and 23) .Results of diagnostic and therapeutic tests and procedures

1. If a member of the care team updates Ella’s chart to include the missing element(s) after being alerted of the omission, could this element still be a red flag for an on-site TJC surveyor?

2. How would you propose the different departments within the hospital work both independently and collaboratively to ensure all elements are met? Explain your answer.

3. What policies could the General Hospital put in place to ensure the missing element is always documented in the chart?

Standard RC.02.01.01 The medical record contains information that reflects the patient’s care, treatment, and services Element of Performance for RC.02.01.01 C 2. The medical record contains the following clinical information: R . The reason(s) for admission for care, treatment, and services . The patient’s initial diagnosis, diagnostic impression(s), or condition(s) Any findings of assessments and reassessments (See also PC.01.02.01, EPs 1 and 4; PC.03.01.03, EPs 1 and 8) Any allergies to medications patient’s medical history and physical examination patient’s course of care, treatment, and services . Any allergies to food Any conclusions or impressions drawn from the Any diagnoses or conditions established during the including complications and hospital-acquired Any consultation reports Any observations relevant to care, treatment, and services The patient’s response to care, treatment, and services -Any emergency care, treatment, and services provided to the patient before his or her arrival . Any progress notes All orders Any medications ordered or prescribed strength, dose, and route devices used, and rate of administration Any medications administered, including the Any access site for medication, administration Any adverse drug reactions Treatment goals, plan of care, and revisions to the plan of care (See also PC.01.03.01, EPs 1 and 23) .Results of diagnostic and therapeutic tests and procedures