Determine medical staff compliance with hospital policy relating to delinquent records.Professional Practice Activities (PPA) are activities designed to expose you to real, sometimes virtual, professional/healthcare practices.
Professional Practice Activities (PPA) are activities designed to expose you to real, sometimes virtual, professional/healthcare practices. For students enrolled in the Health Information Technology Program, PPAs are a required part of the curriculum mandated by the American Health Information Management Association (AHIMA).
Objectives
Upon completion of this activity, the student should be able to:
Determine medical staff compliance with hospital policy relating to delinquent records.
Calculate delinquency rates for health records, history and physicals, and operative reports.
Construct data displays using Microsoft Excel.
Analyze data and prepare a report regarding medical staff compliance with Joint Commission standards.
Instructions
For the purpose of this assignment, assume that you are the manager of the HIM Department of General Hospital. General Hospital is due for a Joint Commission accreditation survey in six months. The CEO asks for a report regarding medical staff compliance with Joint Commission requirements for delinquent records last year. The following are the two Joint Commission standards that address timeliness of medical record completion.
General Hospital is due for a Joint Commission accreditation survey in six months. The CEO asks for a report regarding medical staff compliance with Joint Commission requirements for delinquent records last year. The following are the two Joint Commission standards that address timeliness of medical record completion.
Joint Commission Standard Record of Care, Treatment, and Services (RC) RC.01.03.01
Documentation in the medical record is entered in a timely manner.
Elements of Performance RC.01.03.01
The hospital has a written policy that requires timely entry of information into the medical record.
The hospital defines the time frame for completion of the medical record, which does not exceed 30 days after the patient’s discharge.
The hospital implements its policy requiring timely entry of information into the patient’s medical record.
Joint Commission Standard Record of Care, Treatment and Services (RC) RC.01.04.01
The hospital audits its medical records.
Elements of Performance RC.01.04.01
The hospital measures its medical record delinquency rate at regular intervals, but no less than every three months.
To implement this standard, General Hospital’s policies and procedures state:
The medical record delinquency rates are monitored on a monthly basis;
Action will be taken when a problem is indicated; and
Data will be available to demonstrate improvement.
In addition, to ensure the timely entry of all significant clinical information into the patient’s record, the Medical Staff Rules and Regulations list the following documentation requirements:
The total number of delinquent records may not exceed 50% of the total number of inpatient discharges and ambulatory surgeries performed for the month.
The total number of delinquent history and physicals may not exceed 2% of the total number of inpatient discharges and ambulatory surgeries performed for the month.
The total number of delinquent o
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