Joint commission standards for history and physicals

Professional Practice Activity - Delinquent Record Statistics

Professional Practice Activities (PPA) are activities designed to expose you to real, sometimes virtual, professional/healthcare practices. For students enrolled in the Health Information Technology Program, PPAs are a required part of the curriculum mandated by the American Health Information Management Association (AHIMA).

Objectives

Upon completion of this activity, the student should be able to:

Determine medical staff compliance with hospital policy relating to delinquent records.
Calculate delinquency rates for health records, history and physicals, and operative reports.
Construct data displays using Microsoft Excel.
Analyze data and prepare a report regarding medical staff compliance with Joint Commission standards.
Instructions

For the purpose of this assignment, assume that you are the manager of the HIM Department of General Hospital. General Hospital is due for a Joint Commission accreditation survey in six months. The CEO asks for a report regarding medical staff compliance with Joint Commission requirements for delinquent records last year. The following are the two Joint Commission standards that address timeliness of medical record completion.

General Hospital is due for a Joint Commission accreditation survey in six months. The CEO asks for a report regarding medical staff compliance with Joint Commission requirements for delinquent records last year. The following are the two Joint Commission standards that address timeliness of medical record completion.

Joint Commission Standard Record of Care, Treatment, and Services (RC) RC.01.03.01
Documentation in the medical record is entered in a timely manner.

Elements of Performance RC.01.03.01

The hospital has a written policy that requires timely entry of information into the medical record.
The hospital defines the time frame for completion of the medical record, which does not exceed 30 days after the patient's discharge.
The hospital implements its policy requiring timely entry of information into the patient's medical record.
Joint Commission Standard Record of Care, Treatment and Services (RC) RC.01.04.01
The hospital audits its medical records.

Elements of Performance RC.01.04.01
The hospital measures its medical record delinquency rate at regular intervals, but no less than every three months.

To implement this standard, General Hospital's policies and procedures state:

The medical record delinquency rates are monitored on a monthly basis;
Action will be taken when a problem is indicated; and
Data will be available to demonstrate improvement.
In addition, to ensure the timely entry of all significant clinical information into the patient's record, the Medical Staff Rules and Regulations list the following documentation requirements:

The total number of delinquent records may not exceed 50% of the total number of inpatient discharges and ambulatory surgeries performed for the month.
The total number of delinquent history and physicals may not exceed 2% of the total number of inpatient discharges and ambulatory surgeries performed for the month.
The total number of delinquent operative reports may not exceed 2% of the total number of inpatient operations and ambulatory surgeries.

Download the following Delinquent Record Report.

Using Microsoft Excel, input the data from the Delinquent Record Report. Include report, column and row titles, and the monthly data.
Use Excel to calculate and automatically insert the total number of discharges for the month. Total discharges = Total Inpatient Discharges + Total Ambulatory Surgeries, for purposes of delinquent record calculations. Total operations = total ambulatory surgeries + total inpatient operations.
Use Excel to calculate and insert the number of delinquent records, history and physical exam reports (H & Ps), and operative reports permitted according the Medical Staff Bylaws for each month in 20XX based on the hospital's statistics for that month. To calculate the year's figure, the monthly average should be used. Therefore, have a final monthly average column and use Excel to compute the averages for all rows.
Using Excel, construct both line graphs and bar graphs showing the following
The hospital's actual delinquent records compared to the total number of delinquent records permitted by the Medical Staff Rules and Regulations for the 12 months in 20XX (do not include the total for the year)
The hospital's actual delinquent H & Ps compared to the total number of delinquent H & Ps permitted by the Medical Staff Rules and Regulations for the 12 months in 20XX.
The hospital's actual delinquent ORs compared to the total number of delinquent ORs permitted by the Medical Staff Rules and Regulations for the 12 months in 20XX.
Consider which of the graphs do you prefer to illustrate the hospital's compliance?

Provide a narrative analysis of the findings for the CEO. Reference the table and use the graphs you prefer to illustrate compliance in the report. Include in the analysis whether the hospital was in compliance with the Medical Staff Rules and Regulations in each of the three areas during each month of the year. Was the hospital in compliance for the whole year?
Submit the following to your instructor:
Delinquent Record Report Table
Line and bar graphs
Narrative analysis of findings.
Evaluation

This activity will be evaluated for:

Accuracy of spreadsheet - Delinquent Record Report
Accuracy and appearance of line and bar graphs
Content and analysis of findings in the report for the CEO
Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

Save your assignment as a Microsoft Word document. (Mac users, please remember to append the ".docx" extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown below:

Jstudent_exampleproblem_101504

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