To: From: Date: Re:
Executive Management, Nightingale Community Hospital Brittany Amon, Senior Audit Administration September 29, 2012
Compliance Status of Nightingale Community Hospital: Information Management
The following pages will provide a summary of the current compliance status of Nightingale Community Hospital based on the Information Management Priority Focus Area. From the information provided by Nightingale Community Hospital [the hospital] or readily available to the audit team, many Joint Commission standards are not currently being met and will require corrective action prior to an audit to ensure success. The next Joint Commission visit is anticipated in 13-months, and the hospital should focus on fixing these areas before then. These three standards include multiple Elements of Performance [EPs] that the hospital should be sure are implemented within policies or procedures that are able to be referenced by the Joint Commission. These standards were chosen by the hospital as the items to be internally pre-audited because it is understood that these are key issues in the proper operation of the hospital and protection of the patient’s data: 1) IM.02.02.02 – This standard ensures the hospital is effectively managing the collection of health information. This standard was chosen for this section because this is the very start of the hospital’s responsibility to maintain accurate and secure information for a patient. The process of Information Management starts with this standard being met. 2) RC.01.01.01 – This standard ensure the hospital maintains complete and accurate medical records for each patient. This standard carries over importance from the previous mentioned standard. This ties into Information Management for the hospital because after the data is collected, the hospital must maintain it properly to be within compliance and protect their patients’ information. 3) RC.01.04.01 – This standard ensures hospitals audit their medical records. This also follows the same trend as the first two standards chosen, because in order to properly manage the information, periodic audits must be taken to confirm previous policies and procedures are not only being followed by staff, but are working in the hospital’s favor by meeting compliance and hospital standards. Page 1 of 5
Standard Label & Text (The Joint Commission, 2012) IM.02.02.01 The hospital effectively manages the collection of health information.
Current Compliance Status of Nightingale Community Hospital: Information Management Elements of Performance Does Nightingale Have a Corrective Plan of Action (EP) Corresponding Policy or (if applicable) Procedure to Address the EP? 1) The hospital uses uniform data sets to standardize data collection throughout the hospital. 2) The hospital uses standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations. 3) The hospital follows its list of prohibited abbreviations, acronyms, symbols, and dose designations, which includes the following: U,u; IU; Q.D., QD, q.d., qod; Trailing zero (x.0 mg); Lack of leading zero (.X mg); MS; MSO4; MgSO4. 1) The hospital defines the components of a complete medical record. 4) The medical record contains information unique to the patient, which is used for patient identification. 5) The medical record contains the information needed to support the patient’s diagnosis and condition. Yes; The Admission Order form allows for collection of standardized information. Yes; Both the Admissions Order form and the "Prohibited Abbreviations" Patient Care Policy follow standardized criteria. Yes; The Patient Care Policy "Prohibited Abbreviations" provides the list of prohibited abbreviations and reasoning behind not using them. Ensure all other forms other than the Admissions Order form also are using the same standardized criteria as indicated in the EP. Ensure all other forms other than the Admissions...