Nightingale Community Hospital

...

The third EP, which examines whether the hospital follows a list of prohibited abbreviations, acronyms, symbols and dose designations, needs great attention. (The Joint Commission, 2013) According to the National Patient Safety Goal Data: Information Management report, there was a very high percentage of unacceptable abbreviations used in the months of January and December. The goal is to have a compliance rate of 99.6%. In order to achieve compliance with the Joint Commission, a corrective action plan must be set in place, which can start by having an internal audit group. This group of personnel will be responsible for running monthly audits to ensure that the hospital is operating within its compliance goals. They will also hold the responsibility of identifying those areas that do not meet the compliance standards and come up with ways to address the issue, by developing training programs and compliance trainings. It will be very vital to conduct these audits on a regular basis so that errors can be identified and resolved so that the hospital will be able to meet the compliance standards that are set by the Joint Commission.

The second priority focus area is RC.01.01.01 which examines the hospitals maintenance of complete and accurate medical records for each individual patient. There are a number of EPs that coincide with this priority focus area, such as ensuring that medical records contains information that are unique to the patient and information regarding the patients care treatment and services that will ensure that the patients will continue to use the care provided at this hospital. The EPs also ensures that all medical records are dated and that the records provide all required information to make sure that the patient is receiving the treatment that is needed. (The Joint Commission, 2013) In regards to this priority focus area, Nightingale Community Hospital seems to be operating in accordance to the standards set by the Joint Commission.

The third and final priority focus area is RC.01.04.01, which examines whether the hospital audits its medical records. There are three EPs that coincide with this Priority focus area. The First EP examines whether the hospital conducts an ongoing review of medical records at the point of care based on the certain indicators such as presence, timeliness, accuracy, authentication and legibility. The next EP examines whether the hospital measures the delinquency rate of medical records at regular intervals, no less than three months. The final EP examines whether the medical record delinquency rate from the last four quarterly measurements less than or equal to 50%of the average monthly discharge. (The Joint Commission, 2013)

...