chapter 17 case study
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School
School for Professional Studies, CUNY *
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Course
450
Subject
Information Systems
Date
Dec 6, 2023
Type
docx
Pages
1
Uploaded by KidBook8696
Radhika Rana Basra
12/2/2023
The data supplied indicates that the most often occurring quality key code is 2, signifying "No
H&P prior to surgery." Given that both entries for this service (patients 14 and 15) have problems
with the operative report not being dictated within 24 hours of operation, it appears that OB is
the problematic service. It is clear from the data that there are problems with documentation
standards compliance, particularly with the history, physical reports, and operational reports.
The PI Plan can incorporate the following actions to address the documentation compliance
issues:
1.
Education and training: Educate and teach healthcare personnel on the significance of
prompt and accurate documentation, particularly for surgical, physical, and history
reports. Stress the repercussions of non-compliance and offer instructions on how to
adhere to the paperwork requirements.
2.
Workflow improvement: To find any bottlenecks or inefficiencies, assess the present
workflow for historical, physical, and operational reports. Simplify the procedure and
make sure that there are defined roles and duties for promptly finishing and updating the
documentation.
3.
Automated alerts and reminders: Put in place a system that notifies healthcare personnel
by email when paperwork is past due or due on time. By doing so, you may increase
punctuality and make sure that no paperwork is missed.
4.
Monitoring and auditing: To monitor and evaluate adherence to documentation
requirements, set up a routine procedure for monitoring and auditing. This can include
regular reviews of documentation in patient records, as well as conducting random audits
to ensure that the required documentation is completed in a timely manner.
5.
Build a feedback loop and framework for ongoing development to achieve continuous
improvement. Determine any patterns or reoccurring problems by periodically reviewing
the monitoring and auditing process data. Make the required modifications to procedures,
guidelines, and educational initiatives using this data to guarantee continued adherence to
documentation requirements.
The hospital can improve the timeliness and accuracy of documentation for history, physical
reports, and operative reports by putting these steps into place and addressing the documentation
compliance issues that have been discovered. By doing this, the hospital will be able to meet the
Joint Commission documentation standards and guarantee improved patient care, efficient
communication, and compliance with all applicable laws. The use of routine monitoring,
auditing, and continuous improvement initiatives will aid in maintaining the gains made thus far
and averting more compliance problems.
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