Answer Happy

Figure 17.6. Data for timeliness of documentation study Procedure End Time 12/23/2018, 17:50 12/04/2018:09:45 12/10/2018, 09:45 12/19/2018, 14:26 PATIENT DISCHARGE SERVICE QUALITY Admit Physician Action Procedure DATE CODE Date & Start Time Time 1 12/23/18 CD 12/23/2018; no time noted on H&P 12/23/2018 16:20 12:30 update stamp 2 12/04/18 EN 12/04/2018; H&P dated June 2018 12/04/2018;09.15 07:04 3 12/10/18 EN 12/10/2018: H&P signed, dated & H& 12/10/2018, 08:44 06:47 timed on 12/10/2018 at 05:05 4 12/19/18 EN 12/19/2018 Op report dictated 12/19/2018: 13:02 12/22 5 12/09/18 EN 12/07/2018; no date/time on H&P ; 12/07/2018; 07:51 12/07/2018, 09:15 06:14 6 12/26/18 GS 12/26/2018 H&P dated 11/24/2018 P 7 12/26/18 GS 12/26/2018 Op report not dictated 12/26/2018: 11:21 12/26/2018, 14:08 8 12/26/18 GS 12/26/2018 H&P dated 11/21/2018 9 12/30/18 GS 12/21/2018 Op report dictated 12/21/2018 01/09/19 10 12/23/18 NE 12/15/2018: H&P dictated 12/15/2018, 11:44 12/15/2018, 15:32 08:26 12/18/2018 11 12/20/18 NE 12/18/2018 H&P dictated 12/18/2018, 07:25 12/18/2018, 08:45 05:26 11/03/2018 12 12/11/18 NE 12/11/2018 H&P dictated post-op 12/11/2018, 07:22 12/11/2018 11:46 13 12/16/18 NE 12/16/2018: H&P dictated 12/16; : HP 12/16/2018, 07:51 12/16/2018, 09.01 04:56 05:59 14 12/27/18 OB 12/25/2018, 16:00 12/25/2018, 16:42 12/24/2018; Op report dictated 22:15 12/29/2018 01/03/19 OB 15 12/29/2018: 13:51 12/29/2018; Op report dictated 12/29/2018, 14:40 02:14 12/29/2018;1500 12/04/2018: 05:25 12/04/2018: 06:32 16 12/04/18 12/04/2018: Op report dictated OR 04:30 12/23/2018 12/17/2018, 14:03 12/17/2018:12:47 12/17/2018: H&P dictated 12/15 OR 17 12/17/18 09:52 12/15/2018, 12:41 P 12/15/2018; Limited H&P completed 12/15/2018:07:39 OR 12/18/18 18 05:14 12/15:07:30 12/04/2018 13:09 12/04/2018; Limited H&P signed/ OR 19 12/12/18 10:10 dated/timed as 1100 after analysis 12/03/2018 23:46 12/03/2018: No H&P dictated OR 20 12/06/18 17:10 12/15/2018: 08:54 12/15/2018; Op report dictated OR 12/15/18 21 06:45 12/16/2018 1055 12/05/2018: H&P update dated/ 12/05/2018;08:14 UR 22 12/05/18 07:00 timed 12/5; 0900 post analysis Key 1 = H&P >30 days 2 - No H&P prior to surgery 3 = No update to H&P prior to surgery 4 = No Operative report within 24 hours after surgery 12/04/2018, 16:53 12/04/2018; 01:28 12/15/2018: 10:42 12/05/2018, 09:59
documentation. The facility is due for another survey very soon. To ensure that the hospital is in compliance with the Joint Commission documentation standards, you need to conduct a quality audit. This audit should carefully assess documentation compliance for history and physicals (H&Ps) and operative reports (Ops). A history and physical report must be available in the patient's health record before any sur begin. The H&P can be completed up to 30 days prior to the procedure as long as the surgeon updates any information prior to starting the procedure. The Op must be dictated by the surgeon within 24 hours of the procedure to be compliant. You have assigned one of your staff to collect data from patient records to accomplish this task. The staff member collected data for the month of December for gical procedure can quality and timeliness of documentation. The data collected are presented in figure 17.6. Case Study Tasks 1. Review the collected data. 2. Assign the appropriate quality code using the key located at the bottom of figure 17.6. 3. Analyze the data: a. Which code is most common? b. Is there one service that seems to be a problem? c. What can you conclude from the data about compliance with documentation standards? 4. What measures do you need to implement to correct any documentation compliance issues?