HIM 200 Final Project

Robin McFadden

Southern New Hampshire University

Intro to Health Information Management

Instructor Sherry Ferrell

June 17, 2022

In healthcare, the most important document is the health record. A health record must be

accurate and complete for a patient to receive the safest quality of care and for a healthcare to be

able to provide that to them. The Joint Commission has standardized the way information in

health records must be provided at all hospitals. This helps ensure patient care, and that a

hospital is motivated to keep their accreditation. Noncompliance opens the door to negligence

and malpractice suits that could have easily been avoiding. The Joint Commission standards are

here for the protection of patients and providers in healthcare.

Patient Health Record and Review of Record

Upon reviewing the Health and Physical Examination of Pam Ray, she is a 63-year-old

female with no known family history of diabetes, tuberculosis, or heart disease. She underwent

an extraction of six mandibular teeth and a mandibular alveolectomy performed by Dr. John

Black DDS. For this procedure she was placed under general anesthesia and per her Medication

Administration Record, Ms. Ray was prescribed Tylenol and Tylenol with codeine up to four

times a day.

In accordance with their website, “The Joint Commission standards are the basis of an

objective evaluation process that can help health care organizations measure, assess, and

improve performance. The standards focus on important patient, individual, or resident care and

organization functions that are essential to providing safe, high quality care. The Joint

Commission’s state-of-the-art standards set expectations for organization performance that are

reasonable, achievable, and survey-able.” (TJC E-dition, 2020) These standards are evaluated at
facility once every 36 months for a facility to keep their accreditation. Even after standards are in

effect, continuous feedback from healthcare is sought after so it may be improved, so facilities

are always being notified of changes, so they stay compliant.

I found after, reviewing the entirety of Ms. Ray’s health record, it was not in compliance

with the standards of Record of Care (RC) which the Joint Commission regularly reviews to

ensure accuracy of documented information. On the Health and Physical Examination, the name

listed was incorrect and there was no date of birth. The provider did not sign under discharge

instructions, and the Face Sheet had no ICD CODES listed. (RC.02.01.01) There was a violation

of (RC.01.02.01) since in the Discharge Summary, Inpatient Face Sheet, and Consent to

Admission the provider and patient’s signature are missing (TJC E-dition, 2020). The progress

notes on 4/18 font size decreased which could making reading it difficult, making it a direct

violation of the TJC standard RC.01.04.04 which reflects how the facility audits their own

records and elements of performance, which includes legibility of their notes, handwritten or

typed (TJC E-dition, 2020). Also, in the progress note from 4/19, and the discharge summary the

date and time stamp are missing. To care for a patient accurately, the facility must know what

time any action was taken. This discharge summary did not include follow up information for the

patient’s, diet, activity, and progress/goals. For proper care and healing, the patient needs to

know what continued care such as physical activity, restrictions and diet is needed once they are

outpatient.

There are many violations that the Healthcare staff incurred regarding the health record

of Pamela Ray. The patient and provider’s signature missing on the Discharge Summary,
Inpatient Face Sheet, and Consent to Admission is not in compliance with the Joint Commission

guidelines and in direct violation of (RC.01.02.01). The Advanced Directive do not have the

patient initials and the wrong name is listed, and the progress notes missing time stamps that are

required (RC.01.01.01) (TJC E-diction, 2020). All these violations mean that the patient is not

getting the safest, quality healthcare they are entitled to, and it is enabling providers from being

able to accurately practice. The providers rely on this information and not being able to read it

legibly can hinder that and is also a violation. All these violations put the hospital at risk of loss

of accreditation.

Every healthcare facility is aware of the steps it needs to take to ensure compliance the

Joint Commission to ensure quality patient care and to keep their accreditation. This hospital

facility having a number of violations is something they need to work on promptly because too

many mistakes were made that should not have been missed. The compliance standards are the

same across the board and should be followed the same across the board to ensure a smooth

transition in the information delivered from patient to provider and provider to provider.

Systems and Technology

This organization collects and enters data manually. Doing data entry manually is very

time-consuming and exposes you to a higher risk of error. When documenting a patient record,

you must be quick and concise, and entering a record this way is not the best method to be

implemented. I would recommend system customization for this organization, “system

customization includes loading data tables and master files, adjusting decision support rules for

transitioning, writing interfaces, customizing screens, and numerous other tasks that make the

system work for the specific organization” (Oachs & Watters, 427). The workstations on wheels

or the WOWs, as they were put, are a dangerous trip and fall hazard being that they must be
plugged in and occupy the hallway. After using the computer, the HIM professional must always

remember to log out, to not expose sensitive information to someone who should not see it.

The main gaps and issues with the functionality of the current collection and storage

systems that I noticed were the data system that is currently being used are very vulnerable to

fire, flood, and explosion. The charts need to be more easily accessible because if there is not a

WOW machine available, the HIM may have to wait and that is a waste of time. There also

needs to be a way to quickly be able to access patient information without having to type in the

medical record.

The best recommendations that I could give to correct the gaps in technology for this

organization would be first, to move the work stations to a place easily accessible when near

patients and stationed near a power source so that they can always be charged, not block the

hallways and not have to be waited on to be used by someone who needs it. There should be a

system in place that inputs patient vitals automatically so that they do not have to be manually

entered. A secondary location should be used for the data center to reduce the risk of the data

being destroyed. Cloud storage would be a great benefit to this organization because with cloud

storage it is not stored near the facility where it is being used, so there is no risk of information

being lost or destroyed. The cloud storage is very expansive, so there will be plenty enough room

for however much information this organization needs to store. After this organization makes

their changes, “a number of steps should be taken to ensure that the system is working as

intended. These include monitoring of use, ensuring adoption of the system, checking that

intended benefits realized, assuring that the system is properly maintained, installing upgrades,

making enhancements as applicable, and replacing elements of the system as necessary” (Oachs
& Watters, 429). With these provisions, I believe that the facility can correct and keep the

changes up to date.

Secondary Data Sources

The data that is collected from the primary source is then used as a secondary data

source. Things such as reports, registries; facility or population-based, facility-specific indices,

and other healthcare databases are examples of secondary sources. Secondary data are

considered aggregate data which is, data on groups of people or patients without identifying a

specific individual. There are two types of users of secondary data, external and internal users;

they use the information provided in the secondary data source to get information that is not

readily available in a health record. Internal users are people in healthcare facilities such as

medical, administrative, and management staff. They use secondary data to determine the

patterns and trends that are useful in-patient care such as budgeting, long-range planning, and

benchmarking with other facilities. Individuals and institutions such as state data banks and

federal agencies located outside of the facility are considered external users. Also, “The federal

government collects data from the states on vital events such as births and deaths. The secondary

data provided to external users is aggregate data and not patient-identifiable data. Thus, these

data can be used as needed without risking breaches of confidentiality.” (Oachs & Watters, 176).

Data Elements

The patient's demographics, type of cancer diagnosis, tumor histology, treatment, and

outcome information are all collected for registry purposes. Depending on the registry's specialty

(kind of cancer, survivability), organizations may have additional requirements. Sensitive

Healthcare facilities need a policy around the governance of data collection and

privacy of the registry for overall protection of the individual’s information. They need to be sure

they are following HIPPA guidelines to protect themselves and the patient from any sort of data

breach that may come from releasing the information, and only the information needed, and they

also need to inform the patient of their plans for using the information for registry purposes.

Data Requirements

Following the audit of the medical health record, the name and billing/insurance of the

patient was determined information, physician signatures, and time and date stamps are all data

items that are required to ensure patient safety and compliance. Verifying that the patient signs

the consent form allowing the healthcare facility to perform the treatment to assist her. ("The

Joint Commission E-diton", 2019). For each patient it treats, the hospital is expected to keep

accurate and comprehensive medical records. Demographic data, diagnosis, and treatment,

signed consent papers, and discharge information are all included. The health professionals must

enter the data in a timely manner, date it, and sign it.

Organization’s Compliance

There were various standards that the hospital had failed to follow while examining Pam

Ray's patient health record. The hospital must verify that all paperwork includes the patient's

name and date of birth. The information on patient charts must be legible to avoid improper

patient care and a missed diagnosis, the inpatient fact sheet should include the patient's insurance

information, and the hospital must ensure that all documents requiring the patient's signature are
full and signed. To be in compliance with TJC guidelines, they must complete the discharge

statement within thirty days of discharge. Another person's name was listed in place of Pam

Ray's in one area. For accuracy, her name should appear on every page of her medical records.

This is a violation of TJC norm RC.01.01.01 and must be remedied promptly.

Registry Compliance

To comply with local and national data registries, the hospital must correct the issues

discussed previously. Pam Ray's chart includes information about her occupation and

demographics “Cancer registries collect many different types of data, including patient

demographics, tumor (cancer) characteristics, treatment, and outcomes. After collecting the data,

registries store and manage them” (National Cancer Institute, 2021). Because the patient does not

have cancer, it is difficult to determine if the hospital is using EHRs to comply with cancer

registries. The medical record is insufficient and lacks critical information, making it non-

compliant with TJC requirements. To comply with TJC requirements, the hospital must address a

number of difficulties. If the data is provided to cancer registries, it may have an impact on data

management. The hospital must have backup storage in a climate-controlled, secure room with

generators or it is in violation of TJC standard IM 02.01.03. EP2.

Recommendations

My recommendations for this facility are, that the hospital should ensure that all

employees are working in accordance with TJC guidelines. Data loss and entry delays could be

avoided by implementing an automated data system. It would also be beneficial if the hospital

implemented policies requiring all data input to be completed and documented within a certain

amount of time. In addition, the author who is writing the documents must sign the pages. The
personnel must also ensure that the patient signs all consent documents, as well as consent for

treatment and all operations. As a result, I propose that the hospital develop policies to inform

workers about their responsibilities. Clinicians could examine patient health data for inaccuracies

on a regular basis to be proactive and prevent compliance issues. Cloud storage for is advised

because storing health records in a secure cloud database takes less time and allows practitioners

easier access, which reduces the chance of data entry errors. This will add an extra degree of

security before accessing the internet, allowing clinicians to transmit information to patients they

would like to have access to in the hospital for post-discharge follow-up care.
 References

Data Collection, Storage, & Management. (2021). SEER.

https://seer.cancer.gov/registries/cancer_registry/data_collection.html

How Cancer Registries Work | CDC. (2021). CDC.GOV.

https://www.cdc.gov/cancer/npcr/value/registries.htm

The Joint Commission E-dition. (2020). Record of Care, Treatment, and Services.

Retrieved from https://e-dition.jcrinc.com/MainContent.aspx

Oachs, P. K., & Watters, A. L. (2016). Health Information Management: Concepts, Principles,

and Practice (5th ed.). AHIMA.