The Nightingale Hospital Next Joint Commission Inspection.

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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…show more content…
The Information Technology Manager is to develop a Standard Operating Procedure for all Care Units to require the use of computerized demographic labels printed on-demand from Hospital LIS at the time of initiating patient orders. The labels’ quantity must be sufficient for each patient’s order to be placed on appropriate forms, as well as on all sample containers and tubes at the time of collection. Internal Audits are to be conducted on a quarterly basis in order to determine the effectiveness of this change. 4. QA/RA Department Manager is to develop and implement an organization-wide Policy and Standard Operating Procedure for conducting Internal Audits, which should closely follow recommendations of Joint Commission and other regulatory agencies. Information Management is one of the organizational management chapters in the JACHO Accreditation Manual for Hospitals. According to this document, organizations must have well-developed processes for managing of patient data, including, but not limited to, initial recording, retrieving, reporting, and displaying of all patient-related information associated with specific patient care activities1. The importance of information management in the clinical setting has never been more vital. Accuracy of recordings and ease of understanding of patient information in medical records play central role in quality of

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