HIM 200 Milestone One_3_21_2024

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Southern New Hampshire University *

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200

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Health Science

Date

Apr 3, 2024

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docx

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Uploaded by michelleabbt

1 Analysis of Health Record and Joint Commission Michelle Abbt Southern New Hampshire University Analysis of Health Record and Joint Commission A patient health record (PHI) is a compile of both clinical and administration details within a patient’s chart. When a facility fails to provide the proper records that needed for the

2 safety and accreditation standards this can be of great consequence with the information that is within the patient’s health record. Having the correct and accurate information in the patient health record is of great importance, and also is crucial to both the patient and the integrity of the medical facility. When a patient is being admitted or a admirative procedure, the following personal information is would be added the patient health record (PHR), both clinical and administrative note, which would include the patient name, address, date of birth, contact information, emergency contact, etc. at which time, medication and insurance information is collected and added to the PHR. Inside the PHR, you are able to view clinical notes, test results, vitals signs form current and past visits. This type of clinical information is from orders that were written by a physician. Patient Health Record and Review of Record Information pertaining to patient Ray, Pam, regarding her past medical history can be found on the history and physical exam page of the patient’s chart, it appears the patient does not have family history of having diabetes. The patient was admitted on April 18, for an extraction of six mandibular teeth which are abscessed, which is also called a Mandibular alveolectomy, Dr. John Black was the physician conducting the procedure, which was conducted under a general anesthesia with lidocaine, the patient was prescribed Tylenol with codeine for her pain management. Patient is to take medication for the next 10 days, one pill every four hours as needed for her pain. This information is located within the medication administration record.

3 Joint Commission Standards and Expectations To ensure that the medical facility is correctly documenting medical information, medical facilities use The Joint Commission (TJC) standards of Record of Care (RC). Hospitals are required to maintain accurate and complete medical records for each patient, the entries are to be entered into the patients chart in a timely manner, as well as being reviewed by the medical staff member who had provided services rendered with a signature, date and time, according to The Joint Commission (TJC). Patient’s charts are checked periodically by TJC, ensuring the medical facility is following the rules and regulations, also issuing the facilities accreditation and certification. When an organization does not meet the requirements by TJC, the facility will need to make the necessary changes and be reassessed by TJC to mee the proper requirements. Missing Data There are a couple items that are missing within the patient, P. Ray’s chart, that are required that are set in place by TJC, as we look at the Inpatient Face Sheet, the discharge summary and two separate progress notes, the attending physicians’ signature is missing on all sheets, which is a violation of The Joint Commission (TJC), standards RC 01.02.01. (The Joint Commission 2023). Keeping up with the standards of TJC is very important in making sure that the attending physician is not only authenticated the information is correct, but also authorizing the notes in the patient’s chart. As we look further into the patient’s chart, we see that on the Advance Directive page, the patient listed is not that of the actual patient, which is violation of TJC RC.02.01.01. If this is an electronic record, tis section will not be filed in the patient’s chart, which could also create confusion amount other medical staff, this is a huge violation with TJC. Another error is within the Doctor’s Order page, the font is smaller at the 1000-time section, having different font sizes could be an issue with other medical staff that are reviewing the

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