Organizational Strategies & Objectives: JCAH’s documentation standards

Case Study: Chapter 17, p.361

Domain VI.F.5

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During the last accreditation survey, a hospital had findings related to quality and timeliness of documentation. The facility is due for another survey very soon. To ensure that the hospital is in compliance with the Joint Commission documentation standards, you need to conduct a quality audit. This audit should carefully assess documentation compliance for history and physicals (H&Ps) and operative reports (Ops). A history and physical report must be available in the patient’s health record before any surgical procedure can begin. The H&P can be completed up to 30 days prior to the procedure as long as the surgeon updates any information prior to starting the procedure. The Op must be dictated by the surgeon within 24 hours of the procedure to be compliant. You have assigned one of your staff to collect data from patient records to accomplish this task. The staff member collected data for the month of December for quality and timeliness of documentation. The data collected are presented in figure 17.6.

Case Study Tasks

1. Review the collected data.

2. Assign the appropriate quality code using the key located at the bottom of figure 17.6

3. Analyze the data:

a. Which code is most common?

b. Is there one service that seems to be a problem?

c. What can you conclude from the data about compliance with documentation standards? How does JCAH assist in the facility meeting its organizational strategies and objectives?

4. What measures do you need to implement to correct any enterprise-wide documentation compliance issues?

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