Nightingale Community Hospital Jcaho Audit Preparation: Information Management

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Executive Summary

Nightingale Community Hospital is preparing for a Joint Commission on Accreditation of

Healthcare Organizations, or JCAHO, audit. In preparation of the coming audit, Nightingale has released JCAHO’s Priority Focus Areas for the hospital. The priority focus areas outlined are Information Management, Medication Management, Communication, and Infection Control. The area of focus for this assessment will be Information Management. Information management is one of the most important systems in health care. Maintaining a complete and accurate record of the patient’s health care information. The patient’s health record includes all information about the patient, the health
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recommendation for departmental compliance training or organization-wide compliance training. The departments leaders will be responsible for developing a compliance training plan, performing the designated training, then documenting who attended training as well as the training dates. Additional audits will be performed at three month intervals post-training to ensure Nightingale Community Hospital’s and The Joint Commission’s standards are met on a consistent basis.

The next priority focus area is RC.01.01.01 which ensures that the hospital maintains a

separate, complete medical record for each patient. The EPs for this priority focus area include the medical record retention policy and the release of medical records policy (The Joint Commission, 2012). Nightingale Community Hospital appears to be compliant with the Joint Commission’s standards in this priority focus area.

The final priority focus area, RC.01.04.01, which ensures that the hospital audits their

medical records, has three significantly more detailed EPs: 1. The hospital conducts an ongoing review of medical records at the point of care, based on the following indicators: presence, timeliness, legibility (whether handwritten or printed), accuracy, authentication, and completeness of data and information. 2. The hospital measures its medical record delinquency rate at regular intervals, but no less

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