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Scenario: You are the HIM Director at Sacred Heart Hospital. After completing a documentation audit, you have identified three significant issues that you believe do not align with Joint Commission requirements:
History and physical examinations (H&Ps) are not complete (missing chief complaint and review of systems) and are not being done within the required time frame following admission.
Discharge summaries are not complete (missing elements or lack detail) and are not being done promptly upon discharge.
Progress notes are brief, use prohibited abbreviations, and do not describe patient’s condition, including improvement or decline.
You must now create an action plan to correct these issues and improve documentation. You will also conduct a focused audit of three additional charts.
Answer the following questions and submit as a word document or pdf. See the rubric for detailed grading information.
List the JC standard(s) relevant to each of the three identified issues. Include the Standard Label, Standard Text, and the specific Elements of Performance that apply. You must also briefly explain why you think these standards apply.
You may copy and paste the JC standard information, but make sure to strip out all formatting/links. For the Elements of Performance, you only need to copy/paste the relevant portions of text. See the example below.
Create an action plan that answers the following questions:
Which issue(s) would you prioritize and why?
What specific steps would you take to address these three identified issues?
Who would you involve (i.e., physicians, other providers, admin, HIM, etc.) and why?
What type of follow-up would be needed? When/how often would the follow-up occur?
Select three charts (different from the one you selected for the Chart Review project) from the Example Medical Records module (located at bottom of the Modules page). Conduct a focused audit on the three identified issues (H&P, d/c summary, progress notes) and share your findings in a narrative format. Make sure to include the chart IDs (use file name – if I cannot tell what charts you are discussing, you will receive a zero for this question!).
Example for Question #1
Identified Issue: Providers are sharing signature stamps.
JC Standard:
RC.01.02.01 Entries in the medical record are authenticated.
EP 4 Entries in the medical record are authenticated by the author.
EP 5 The individual identified by the signature stamp or method of electronic authentication is the only individual who uses it.
I think that these apply because EP5 states only the individual can use their signature stamp, which sharing clearly violates. Also, EP4 states that the author must authenticate their entry, and if they are sharing signature stamps, authorship/authentication is put into question.
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