Incomplete Record Project
Data Calculations, Standards, and Compliance Notes
there are three links
Course Project: Hospital Data Analysis and Reporting
Objective
The purpose of this Course Project is to apply the knowledge gained in analyzing various performance indicators of a hospital, analyzing trends, determining compliance or poor performance areas, and providing recommendations for improvement or solutions.
Guidelines
For this Course Project, you are asked to analyze a number of status reports for General Hospital, determine compliance with indicators provided to you, and provide suggestions or make recommendations for improvement where needed.
Data on the following indicators are provided in a Microsoft Excel document.
1. Release of Information Reports (ROI)
2. Record Completion: Physician Orders (PO)
3. Record Completion: History and Physical (H & P)
4. Record Completion: Discharge Summary (DC Summary)
5. Report Completion: Operative Report (OP Report)
6. Incident Reports (IR)
7. Standards
8. Rubric (grading rubric)
Part 1: Data Calculations, Standards, and Compliance Notes
Turn the General Hospital status data given for the month of January into meaningful information by performing the following.
Point Values
General Criteria
Specific Data Calculation, Standards, and Compliance Rate Components
40 points
5 points for each type of calculation listed in the last column
Calculations necessary to find completion timeliness for the following on the next column
1. Release of information for all 20 requests (how many days it took to release the information requested)
1. Physician orders (how many days it took every physician to sign each of his or her orders)
1. History and physical dictation (how many days it took to dictate the H & P for each admission—subtract date of admission from the date of dictation)
1. History and physical transcription (how many days it took to transcribe the H & P—subtract date of dictation from the date of transcription)
1. Discharge summary dictation (how many days it took to dictate the DC for each admission—subtract date of discharge from the date of dictation)
1. Discharge summary signature (how many days it took to sign the DC—subtract date of discharge from the date signed)
1. Operative report dictation (how many days it took to dictate the OP report for each admission—subtract date of surgery from the date of dictation)
1. Operative report signature (how many days it took to sign the OP report—subtract date of surgery from the date signed)
15 points
Standards* for the following on the next column
*Standards can be added in each worksheet applicable to the item being analyzed.
1. Completing ROI requests in the cases when records are on-site or off-site
1. Signing orders
1. Dictating a history and physical
1. Signing a discharge summary
1. Dictating an operative report
30 points
5 points for each of the items listed in the last column
Compliance rates based on the standards identified for the following on the next column
1. ROI requests
1. Physician orde
Release of Info Reports (ROI)
Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with the Release of Information Standards. Areas of noncompliance should be identified as well as the standard. Hint: You may use your own state’s Department of Health standards in addition to HIPAA requirements.
Release of Information Report for January
Date Received Client Name Requestor Name Info Disclosed Purpose of Disclosure Date Disclosed Records Offsite Staff ID #
1 1/1/14 Jones, Johnny PCP H & P Continuity of Care 1/21/14 N 14571
2 1/4/14 King, Samantha St. Lawrence D/C Summary Continuity of Care 1/17/14 N 14571
3 1/5/14 Piazza, Anthony PCP D/C Summary Continuity of Care 2/8/14 N 25148
4 1/9/14 Legend, Mary Attorney D/C Summary Litigation 3/3/14 Y 25148
5 1/10/14 Stepnowski, Joseph Robert Wood Johnson X-rays Continuity of Care 1/14/14 N 25148
6 1/11/14 Largent, Khalif Mother D/C Summary At the request of the individual 2/28/14 N 14571
7 1/11/14 Williams, Michael PCP H & P Continuity of Care 1/17/14 N 14571
8 1/15/14 Teller, Aiden PCP D/C Summary Continuity of Care 1/20/14 N 25148
9 1/17/14 Hower, Layla Bayonne Medical Center D/C Summary Continuity of Care 2/26/14 N 14571
10 1/18/14 Cartwright, Renee Robert Wood Johnson Lab reports Continuity of Care 2/1/14 Y 14571
11 1/20/14 Perez, Stacey PCP X-rays Continuity of Care 3/5/14 Y 25148
12 1/21/14 Santoso, Susan Attorney X-rays Litigation 3/1/14 N 14571
13 1/21/14 Williams, William St. Lawrence D/C Summary Continuity of Care 1/28/14 N 14571
14 1/21/14 Abrams, Jonah St. Lawrence D/C Summary Continuity of Care 4/5/14 N 25148
15 1/25/14 Stern, Kimberly Robert Wood Johnson H & P Continuity of Care 1/31/14 N 25148
16 1/25/14 Sran, Timothy PCP Lab reports Continuity of Care 2/5/14 N 25148
17 1/27/14 Berger, Mark PCP X-rays Continuity of Care 2/9/14 N 25148
18 1/28/14 Romano, Maria Attorney D/C Summary Litigation 2/1/14 N 14571
19 1/31/14 Smith, Jennifer St. Lukes D/C Summary Continuity of Care 3/3/14 N 14571
20 1/31/14 Martinez, Alonso PCP D/C Summary Continuity of Care 5/4/14 Y 25148
Record Completion (PO)
Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state’s Department of Health standards.
Physician Order Report for January
Physician : Dr. Jones Physician: Dr. Johns Physicians: Dr. Huffman Physician: Dr. Patrikus Physician: Dr. Leiberman
Client Medical Record #: 123456 Client Medical Record #: 987654 Client
Ambulatory Health Care Accreditation Program
National Patient Safety Goals Effective January 2020
Goal 1
Improve the accuracy of patient identification.
Use at least two patient identifiers when providing care, treatment, or services.
NPSG.01.01.01
Elements of Performance for NPSG.01.01.01
Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-fold: first,
to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the
service or treatment to that individual. Acceptable identifiers may be the individual’s name, an assigned identification
number, telephone number, or other person-specific identifier.
–Rationale for NPSG.01.01.01–
Use at least two patient identifiers when administering medications, blood, or blood
components; when collecting blood samples and other specimens for clinical testing; and
when providing treatments or procedures. The patient’s room number or physical location is
not used as an identifier. (See also MM.05.01.09, EPs 7 and 10; NPSG.01.03.01, EP 1)
1.
Label containers used for blood and other specimens in the presence of the patient. (See
also NPSG.01.03.01, EP 1)
2.
Eliminate transfusion errors related to patient misidentification.
NPSG.01.03.01
Elements of Performance for NPSG.01.03.01
Before initiating a blood or blood component transfusion:
– Match the blood or blood component to the order.
– Match the patient to the blood or blood component.
– Use a two-person verification process or a one-person verification process accompanied by
automated identification technology, such as bar coding.
(See also NPSG.01.01.01, EPs 1 and 2)
1.
When using a two-person verification process, one individual conducting the identification
verification is the qualified transfusionist who will administer the blood or blood component to
the patient.
2.
When using a two-person verification process, the second individual conducting the
identification verification is qualified to participate in the process, as determined by the
organization.
3.
© 2020 The Joint Commission
Page 1 of 11
Ambulatory Health Care National Patient Safety Goals Effective January 1, 2020
Goal 3
Improve the safety of using medications.
Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and
other procedural settings.
Note: Medication containers include syringes, medicine cups, and basins.
NPSG.03.04.01
Elements of Performance for NPSG.03.04.01
Medications or other solutions in unlabeled containers are unidentifiable. Errors, sometimes tragic, have resulted
from medications and other solutions removed from their original containers and placed into unlabeled containers.
This unsafe practice neglects basic principles of safe medication management, yet it is routine in many
organizations.
The labeling of all medications, medication containers, and other sol
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