AMB Surg data collection_Case Study
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University of Illinois, Chicago *
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319
Subject
Medicine
Date
Dec 6, 2023
Type
docx
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3
Uploaded by ChiefKangarooMaster696
University of Illinois at Chicago
Health Information Management Program
Reference:
Foley, D. 2016.
Health Information Management Case Studies.
Chicago: AHIMA
Rev. 10/2020
Name:
Date:
Ambulatory Surgery data collection
Subdomain I.B.2- Verify the documentation in the health record is timely, complete an
accurate.
Subdomain I.D.2 – Apply graphical tools for data presentation
Iron Will Ambulatory Surgical Center provides the following services: Orthopedic,
Oncology, Sports Medicine, Ear, Nose and Throat (ENT), Endocrinology,
Gastroenterology, Cardiology and Pulmonary. Physicians for each service (specialty)
are listed below. The center has a documentation requirement that every patient’s
health record MUST have an H & P prior to surgery. A data collection audit is being
performed to verify compliance with the requirement.
1)
Determine which data element should be included in the data collection.
2)
Create a data collection checklist to be used in the chart review.
Orthopedic- Dr. Berger, Dr. Douglas, Dr. Geneva
Oncology – Dr. Blankenship, Dr. Cohen
Sports Medicine- Dr. Nicols
ENT – Dr. Jones, Dr. Holmes
Endocrinology- Dr. Patel, Dr. Johnson
Gastroenterology – Dr. Smythe, Dr. Wood
Cardiology – Dr. Tyson, Dr. Dr. Griffin
Pulmonary – Dr. Rogers, Dr. Crosby, Dr. Abraham
In July, Iron Will Ambulatory Surgical Center conducted a chart audit to determine
compliance with the H & P on the chart prior to surgery requirement. The results are
as follows:
A total of 1897 surgeries were performed in June:
340 Orthopedic
127 Oncological
85 Sports Medicine
377 ENT
89 Endocrinologic
322 Gastro
279 Cardiologic
278 Pulmonary
160 total charts were reviewed:
Dr. Berger
21 charts
19 with H & P
2 w/o H & P
Dr. Douglas
12 charts
12 with H & P
Dr. Cohen
14 charts
11 with H & P
2 w/o H & P
Dr. Nicols
8 charts
8 with H & P
Dr. Jones
18 charts
18 with H & P
Dr. Johnson
7 charts
6 with H & P
1 w/o H & P
Dr. Smythe
24 charts
20 with H & P
4 w/o H & P
Dr. Tyson
17 charts
15 with H & P
2 w/o H & P
Dr. Crosby
22 charts
22 with H & P
Dr. Abraham
17 charts
16 with H & P
1 w/o H & P
Examine the results of the data collection and answer the following questions.
1)
What deductions can be made about the data collection itself?
2)
Propose a more meaningful data collection.
3)
What deductions can be made regarding the results of the data collection?
4)
Create a graph to depict the data collection results: Based only on the data
collection from the June audit, your graph should accurately reflect the missing
H & Ps (percent or count) by service.
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