Quantitative analysis of medical records

Health Information Management (HIM) professionals ensure all patient health records have no missing reports, forms, or required signatures during the discharge analysis process. Checking to make sure all documents located within the health record have the patient's name and medical record number are also a part of deficiency analysis.

A deficiency slip is completed by the HIM professional when deficiencies are identified to indicate what reports or signatures are missing and which provider needs to complete what's missing.Documentation Deficiency Analysis aka Quantitative Analysis Worksheet As you explain your rationale for a deficiency, please include the agency or organization that governs this area of documentation. 1. Patient came in for elective procedure and in postop recovery they experienced a stroke. After the acute issue was resolved, patient was transferred to a detached facility for recovery. a. What type of summary should the physician be dictating? Explain your rationale. b. What agency or organization governs this area of documentation requirement? 2. Mrs. Johnson was admitted as an inpatient to Rasmussen Hospital on September 16. Dr. Smith dictated a History and Physical report for Mrs. Johnson on September 20. a. Is Dr. Smith’s History and Physical report a deficiency? Explain your rationale. b. What agency or organization governs this area of documentation requirement? 3. Dr. Jones has just completed a cholecystectomy in the Operating Suite and has 15 minutes before his next patient arrives in surgery. a. What do standards require of the physician in regards to this procedure? Explain your rationale. b. What agency or organization governs this area of documentation requirement? 4. Dr. Jefferson forgot to sign one of his progress entered in a patient chart. The patient was discharged 45 days ago. a. Is this patient’s health record deficient? Explain your rationale. b. What agency or organization governs this area of documentation requirement? 5. Mrs. Olson was re-admitted 28 days after discharge for same condition. a. Is it appropriate for the physician to use the same History and Physical Page 1 of 3 Documentation Deficiency Analysis aka Quantitative Analysis Worksheet from her first admission? Explain your rationale. b. What agency or organization governs this area of documentation requirement? 6. Janet Kennedy vaginally delivered a healthy baby boy at Community Hospital. a. What type of documentation is her physician required to dictate? Explain your rationale. b. What agency or organization governs this area of documentation requirement? 7. Nurse Jones phones Dr. Rasmussen at midnight due to a patient spiking a fever after a surgical procedure. Nurse Jones writes the telephone order for the patient to receive Amoxicillin 500 mg. a. What is the timeframe that Dr. Rasmussen has to sign off on the telephone order? Explain your rationale. b. What agency or organization governs this area of documentation requirement? 8. Mr. Klondike was discharged from the hospital on December 18. His physician dictates the Discharge Summary on December 20. a. Is the Discharge Summary a documentation deficiency? Explain your rationale. b. What agency or organization governs this area of documentation requirement? 9. Ted underwent an appendectomy at Rasmussen Hospital. The patient experienced a serious drop in blood pressure while in recovery and was subsequently transferred to the ICU. a. What type of documentation is the physician required to produce for this transfer to ICU? Explain your rationale. Page 2 of 3 Documentation Deficiency Analysis aka Quantitative Analysis Worksheet b. What agency or organization governs this area of documentation requirement? 10. Dr. Jones signs all entries within a patient record on January 8. The patient’s date of discharge from the Rasmussen Hospital was January 7. a. Is the patient’s health record deficient? Explain your rationale. b. What agency or organiz