Accreditation Audit

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  • Published : August 8, 2011
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Executive Summary

Nightingale Community Hospital prides itself on their values, such as safety, community, teamwork and accountability. Yet, we now understand the more has to be done to provide a safer place for our patients. Nationwide, hospitals are trying to find innovative ways to provide safer care and less complication for their employees.

Establishing and encouraging standard practices within the infrastructure of the hospital will reduce chances of human error. With so many physician and staff working at different hospitals and healthcare facilities, variations among these facilities with medical records can result in error and frustration for caregivers. This also brings about a hospital burden because of having to educate, train and provide resources for their own unique facility and policies. Timely medical record documentation and monitoring will help lower this risk and keep the hospital in compliance. Documenting medical records in a timely fashion is an important standard in the Joint commission accreditation process. It requires an accredited hospital to have a have a written policy facilitating the timely documentation into the medical records. Great patient care must have timely completion of medical records. Errors can and will occur if records are not complete and accurate. Not to mention, the patients health could be at jeopardy. Delinquent medical records policy

Nightingale Community Hospital has revised our delinquent medical records policy for physicians and staff in accordance with Joint Commission requirements. The medical records department will closely monitor all records for errors and delinquencies and implement the following steps: 1. Medical record delinquencies must be completed within 30 days from discharge or physicians/staff will receive a certified letter stating a “hold” has been placed on their scheduling of admissions and/or procedures. The “hold” will not be lifted until completion of all errors and...
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