A1. Tracer Evaluation: The patient is a 67year old female that was re-admitted for a surgical infection following an abdominal hysterectomy. She was admitted to the facility seven days ago followed by a surgical procedure which was completed five days prior to this report. Patient is scheduled to be discharged with home health and IV antibiotics. This patient was selected for audit. Review of the chart shows that the patient’s H&P was completed on day 3 of the admission. Joint Commission hospital accreditation requirements for record of care, treatment and services (RC.01.03.01) requires that the patient’s H&P must be completed within 24 hours of inpatient admission (Accreditation Requirements: Hospital: Record of Care, Treatment and Services, 2013) prior to surgery or a procedure requiring anesthesia services. Review of the patient’s chart shows that the facility is not compliant with this standard.
A2. Corrective Action Plan: Timely and accurate documentation of the patient’s condition and plan of care is not only crucial in identifying and communicating the most important aspects of the patient’s clinical needs, it is also mandated as part of the Joint Commission standards (Accreditation Requirements: Hospital: Record of Care, Treatment and Services, 2013) and Medicare’s condition of participation (482.22(c)(5)). The hospital is currently deficient in complying with this regulation as evidenced by late completion of H&P’s. In order to address this deficiency a corrective action plan will be implemented.
Update (or create) the Hospital Policy and Procedure on the Timely Completion of Patient Charts. The policy will address and specify the specific regulatory timeframes for the completion of Admission History and Physical exam (H&P). 2.
Upgrade the hospital documentation system from a handwritten process to an electronic system by securing a dictation program that physicians can utilize for to ease compliance. 3.
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