Week 7. Stephanieorange
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DeVry University, New York *
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Health Science
Date
Feb 20, 2024
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docx
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Uploaded by ChancellorChinchillaPerson1047
GENERAL HOSPITAL
INTEROFFICE MEMORANDUM
TO:
SUSIE JONES, HEAD ADMINISTRATION
FROM:
STEPHANIE ORANGE, HEALTH INFORMATION DIRECTOR SUBJECT:
COMPLIANCE AND NONCOMPLIANCE REPORT
DATE:
DECEMBER 08, 2023
CC:
JERRY BELL, HEALTH INFORMATION SUPERVISOR The purpose of this report is to analyze the data report of General Hospital and highlight the items that comply with the regulations and those that do not. The report will present an overview of the hospital's compliance areas and suggest measures to address the non-compliance issues. Additionally, the report will provide recommendations for improving the hospital's overall performance.
The areas of completion for discharge summaries, operative reports, history and physicals, and physician order reports are all in compliance at 100%. The presented list below shows the complete records.
History and Physical Report
Transcription Completion Rate-100%
Discharge Summary Report
Dictation Completion Rate-100%
Operative Report
Signature Compliance Rate-100%
Physician Order Report
Dr. Jones-100%
Dr. Lieberman-100%
The following areas have been identified as non-compliant with the trend reports: release of information, records completion for physician's orders, history and physical, discharge summary report, operative reports, and incident reports/core measures. Release of Information Report
ROI Compliance Rate-65%
Record Completion (PO) Report
Dr. John-50%
Dr. Huffman-92%
Dr. Patrikus-0%
History and Physical Report
Dictation Compliance Rate-90%
Discharge Summary Report
Signature Rate-55%
Operative Report
Dictation Compliance Rate-85%
Incident Report/Core Measure
Medication error-NPSG.03.04.01; NPSG.03.06.01
Blood transfusion reaction-NPSG.01.01.01; NPSG.01.03.01
Hospital-acquired infections-NPSG.07.01.01; NPSG.07.03.01
Surgical error-UP.01.01.01; UP.01.03.01
The average number of minutes before outpatients with chest pain or possible heart attack got an ECG -9 mins, and the national average -7 mins.
Heart Failure patients given an evaluation of left ventricular systolic (LVS) function- 100%, and the national average- 99%
Based on the non-compliant areas identified in the above reports, there are several recommendations for improvement. Firstly, an improved release of information (ROI) compliance rate can be achieved by implementing a more robust tracking system for ROI requests, ensuring all requests are recorded and tracked until completion. Secondly, to improve the signature compliance rate of the discharge summary report, an electronic signature system can be implemented, which would allow physicians to sign off on reports remotely, eliminating the need for physical signatures. Lastly, to improve dictation compliance rates, physicians can be
offered training and education on proper dictation techniques, including the use of voice recognition software, to improve the overall accuracy and completeness of reports. Additionally, regular audits and feedback sessions with physicians can be conducted to monitor progress and address any concerns or issues that arise. By implementing these recommendations and utilizing the appropriate performance improvement tools and techniques, it is possible to improve compliance rates and overall quality of care.
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