MARIANA MARQUEZ SITAL
ACCREDITATION AUDIT (AFT2)
According to Wikipedia, health information management is the practice of managing health records by hospitals, ……that provide health care or maintenance of health records. The gathering and utilization of health records information is crucial to the improvement of patient care. Information Management is imperative to the everyday operations management of health information and electronic health records. A hospital cannot operate successfully without information management. The information obtained of patient’s treatment visits need to be well documented and recorded in order to provide future health care and retrieval of records.
Wikipedia states that health information management professionals plan information systems develop health policy and identify current and future information needs. Information management is the collection, storage, analysis, use, and transmission of information. Health information administrators play a critical role in the distribution of health care in the United States. Information management supports the practicality and accountability of medical treatment.
Assessment of Nightingale Hospital
The following is an assessment of Nightingale Hospital and how the hospitals’ policies and procedures are in compliance or non-compliant with the Joint Commission standards. The remedy for all incompliance elements of performance is to perform regulatory audits-inspections of all the regulations the hospital could be subject to, along with an assessment of actions (including organization plans) that is required to stay within the rules.
IM.02.02.01 EP 1. Nightingale Community Hospital is in compliance with using standardized data collection throughout the hospital. Nightingale Community Hospital Admission Orders form clearly shows that the hospital uses standardized data collection to document patients’ medical care. NPSG 1and NPSG 2; charts indicate that information is collected and analyzed throughout the hospital.
IM.02.02.01 EP 2 Nightingale’s admission orders form and the Patient Care Policy: Prohibited Abbreviations use standardized terminology, definitions, abbreviations, acronyms, symbols and dose designation. Throughout the hospital, Nightingale uses standardize terminology. For example, NPSG 2 shows the unacceptable abbreviations used and found on medical records; that leads me to believe that abbreviations continue to be in use.
RC.01.01.01 EP 6 Nightingale Hospital is incompliance with this element of performance. The admission orders form requests the purpose for being seeing in the hospital. Furthermore, the form has a section that states if the patient is being referred for consultations and or for health education. The admission order form indicates the treatment and services that are recommended to the patient. The admission orders form contains all the information needed to justify the patient’s care, treatment and services to the patient.
RC.01.01.01 EP 9 The admission orders form does use a standardized format to document the care, treatment and services that are provided to the patients. The admission orders form documents the patient’s treatment at the ER, collects information from the physicians about the patient’s ER visit, and makes recommendations such as referrals and classes.
RC.01.01.01 EP 12 The hospital assembles or makes available in a summary in the medical record all information required to provide patient care, treatment, and services with the form of admission orders. The admission orders form visibly provides a summary of patient’s reason for the ER visits, records vital signs, recommends consultations, medications being prescribed and provides a summary of the patient’s care, treatment and services rendered.
RC.01.04.01 EP 1 Both charts NPG1 and 2 show that the medical records are reviewed as