Question

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.

Record of Care, Treatment, and Services (RC) 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: M AR . 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 food Any allergies to medications Any conclusions or impressions drawn from the patient's medical history and physical examination Any diagnoses or conditions established during the patient's course of care, treatment, and services 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

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?

Answer 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?

These tracers are intended to follow the consideration encounters in association. It is an approach to examine the association's arrangement of giving consideration, treatment or administrations utilizing genuine patients as the structure for evaluating benchmarks consistence. Patients chose for these tracers will probably be those in high-chance territories or whose analysis, age or kind of administrations got may empower the best top to bottom assessment of the association's procedures and practices.

Incorporates an intuitive session with a surveyor and pertinent staff individuals in following one particular "framework" or process inside the association, in view of data from individual tracers. While singular tracers finish a patient consideration, the framework tracer assesses the framework or process, including the reconciliation of related procedures, and the coordination and correspondence among controls and offices in those procedures. The three themes assessed by framework tracers are information administration, disease control and drug administration. Regardless of whether all framework tracers are directed fluctuates, yet the information utilize framework tracer is performed on each review.

They are particularly keen on vertically incorporated e-retailers that make their own marked items and after that offer them on the web, instead of offering items from different brands. A substantial amount of key financial specialists, are taking a gander at carefully local, vertically incorporated brands as a method for extending their promoting nearness.

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

An expansive insurance agency built up another suite of items to meet client needs. However, as the items were taken off, it curved out to be certain that the item improvement and promoting groups had not worked firmly enough with the IT and client benefit groups that should bolster these items. These groups thought about the general item improvement methodology, yet they were excluded in the definite arranging and take off choices, so they were left scrambling to mark up for misplaced period when the items were propelled. Accordingly, clients experienced deferrals and mistakes in preparing, the call focuses were not ready for inquiries, and the general end-to-end cost of the new items wound up being considerably higher than arranged.

A worldwide assembling firm needed to alter an item part for one of its significant clients. Doing as such required broad plan reconfiguration, with changes to hardware, cooling, control, weight, estimating, and item conveyance. Albeit each capacity consented to go up against the progressions that influenced them, they all dealt with them freely and with various time spans. What each capacity didn't understand was that their progressions activated alterations for different offices, and this prompted a nonstop cycle of configuration changes. As an outcome, the item administrator was not able conclude a coordinated plan and still couldn't give the client a firm statement or conveyance plan year and a half later.

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

Apparatuses are expected to help the constant and proficient shared comprehension of a patient's consideration history that all the while helps sound intra-and interdisciplinary correspondence and decision making about the patient's future consideration. Such apparatuses are indispensable to guarantee that the coherence, wellbeing, and nature of consideration continue over the various handovers made by the numerous clinicians associated with a patient's consideration. A main role of documentation and recordkeeping frameworks is to encourage data stream that backings the congruity, quality, and wellbeing of consideration. Since recordkeeping frameworks fill various needs (e.g., lawful prerequisites, accreditation, responsibility, monetary charging, and others), a pressure has emerged and is undermining the main role of the record and rather powering brokenness of consideration, close misses, and blunders. Among the more particular kinds of documentation is the arrangement of consideration, a prerequisite. Though arranging and plans ought to encourage data stream crosswise over clinician suppliers there is minimal generalizable proof about their viability.

Data work is a rudimentary portion of the restorative undertaking. Strauss and Corbin take note of that direction work, as they see restorative consideration, requires data stream when each assignment or errand arrangement to keep up progression of consideration. Errands are not disengaged but rather are interwoven and expand on each other to accomplish understanding objectives. Attendants bear a huge weight in both overseeing and executing the interdisciplinary group's arrangement for the patient, and archiving the consideration and advancement toward objectives. Therefore, medical attendants invest impressive measures of energy doing data work. There are a few kinds of nursing documentation thinks about: those that inspect recordkeeping rehearses in general, those that analyze issues identifying with the documentation (time, substance, fulfillment), and similar assessments of various sorts of changes in the documentation administration including robotization versus paper. Taken together, these give both point by point and wide learning of medical attendants' recordkeeping practices and feature the reasons why any change (manual or electronic) is so hard to incorporate into nursing practice.