Data Management Recommendations for Patient Fall Risk Assessment

Data Management Recommendations Shanta McGraw Southern New Hampshire University HIM-550-Q2400: Data Management & Data Quality 23TW2 Jennifer Horner 1/28/24

Data Management Recommendations As is the case with any information, this data is also utilized to establish rules and procedures and enhance internal operations. Oaks and Watters (2016) state that the data may be used as a basis for change, to evaluate how well our company is performing internally, and to identify areas that require improvement. Happy Healthy Hospital's current data management policy on the completion and documentation of a patient's fall risk assessment is out of date. It has an excessive number of defects and chances for potentially dangerous mistakes. The patient was admitted to the hospital, moved to a new institution, or had a change in their health three days ago. Six patients had their fall risk assessment and paperwork done in compliance with the current guidelines, based on data analysis on seventeen distinct patients. If problems are not quickly found and recorded to guarantee that safety measures are followed, a patient can fall more than once over those three days. HHH should enforce more stringent guidelines for the completion and recording of a patient's fall risk assessment. It is advisable to complete the assessment and documentation as soon as a patient's condition changes, or if they are transferred to another hospital within a day of arriving. By ensuring that HHH is taking proactive measures to safeguard our patients' health and safety and that any fall risks have been recognized and recorded so that the appropriate preventative actions may be performed, this activity will have a beneficial impact on the timeliness of data. Additionally, it will guarantee that the staff members are aware of and have the information needed to keep an eye on the patient. Along with the paperwork and assessment timetable, there will be changes to the information that has to be acquired for the evaluation. The patient's cognitive function, mobility, history of falls, balance issues, hearing or visual impairments, and any current drugs that may increase their

risk of falling will all be considered as part of the fall risk assessment, effective right now. Additionally, in accordance with the SNHU HIM (Health Information Managers) 550 Fall Prevention Policy, "communicate a patient's risk for falling to the healthcare team and family/support system as appropriate for setting (e.g., for inpatients: "Fall Risk" ID bracelet and "Fall Precautions" sign, handoffs, mobility cards, whiteboard)," A nurse or doctor must do the fall risk assessment, document it, sign their name, and note the completion time and date. Currently, the drug profile examination and recording have to be finished within twenty-four hours after admission. This criterion was not satisfied once more, according to the data examined using the same 17 patients as the fall risk assessment. For this section, "unknown" should not be used as the completion source. The medication evaluation and documentation must be finished within the next twenty-four hours, and the doctor or nurse who finished and recorded this step has to be mentioned. By gathering the necessary clinical data, the examination may be finished by the same individual in a whole day. This will guarantee prompt documentation and give all parties engaged with the patient accurate and comprehensive information. There will be no doubts about the accuracy of the information gathered. Health care data governance is a framework for overseeing health information throughout its lifespan, from the moment a patient's data is first entered into the system until long after they are released from the hospital ("What Is Data Governance in Healthcare?", 2017, p.1). HHH is going to implement my advice on this. We will respect the Joint Commission's (JC) guidelines and HIPAA rules, which are as follows:  Take the lead in highlighting how important it is to lower the number of injuries caused by falls.  Create an interdisciplinary team or assess the current team's makeup to reduce falls-related injuries.

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 Employ a tried-and-true technique to determine the variables that raise the chance of falling.  create a personalized care plan based on the patient's recognized fall and injury risks, and deliver treatments in accordance with the patient's needs.  Organize and put into practice tactics and therapies that have been proven effective (Joint Commission, 2015). By implementing these suggestions, HHH is taking the effort to enhance our documentation procedure, guarantee that fall risk assessments are uniform across the board, and safeguard our patients by establishing a safer workplace.

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References Oachs, P.K., & Watters, A. (2016). Health information management: Concepts, principles, and Practice (5ed.) Chicago, IL: AHIMA, American Health Information Management Association SNHU HIM 550 Fall Prevention Policy Preventing falls and fall-related injuries in health care facilities. (2015, September). The Joint Commission, 55 (1). Retrieved from https://www.jointcommission.org/assets/1/18/SEA_55.pdf What is Data Governance in Healthcare? (2017). Retrieved from https://himt.wisconsin.edu/experience-uw-himt/data-governance-in- healthcare

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