The Nightingale Hospital is 13 months away from our next Joint Commission inspection. Although the overall state of compliance for the organization is good, there are several areas that have been identified as “Priority Focus Areas” due to a past history of nonconformities. All these areas are related to Information Management and Record of Care, Treatment, and Services, in particular: A utilization of standardized terminology, definitions and abbreviations, as described in Joint Commission Accreditation Standard IM.02.02.01 Maintenance of complete and accurate medical records for each patient as described in RC.01.01.01. This standard was also identified by JACHO as top compliance issue for the industry. Conducting of Medical Record Audits as described in RC.01.04.01 The areas listed above as Priority Focus Areas for Nightingale Hospital have been evaluated using Internal Audit data. The following findings have been documented: 1. The overall compliance with IM.02.02.01 is satisfactory, with two areas identified as needed improvement: a. The Hospital maintains an active Patient Care Policy for use of prohibited abbreviations, with a separate Addendum listing unacceptable abbreviations, their intended meaning, as well as recommended best practices. Although the list contains the majority of prohibited abbreviations, the following abbreviations listed in IM.02.02.01. were not included: QD, q.d., qd, Q.O.D., QOD, q.o.d, qod. b. The instances of unacceptable abbreviations were reduced to 0.4% by the end of last calendar year, showing substantial decrease in use of most unacceptable abbreviations, with the exception of recording of abbreviation “u” in place of a word “unit”. The instances of using this particular abbreviation have increased from 17% to 63% in the course of a calendar year. 2. The “Admission Orders” form is adequate and fulfills the purpose of recording patient orders appropriately. Section 6. “Medications” contains unapproved abbreviation “pr”...
References: 1Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Standards – July 2012.
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