HIM Director at Sacred Heart Hospital.

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Scenario: You are the HIM Director at Sacred Heart Hospital. After completing a documentation audit, you have identified three significant issues that you believe do not align with Joint Commission requirements:

History and physical examinations (H&Ps) are not complete (missing chief complaint and review of systems) and are not being done within the required time frame following admission.
Discharge summaries are not complete (missing elements or lack detail) and are not being done promptly upon discharge.
Progress notes are brief, use prohibited abbreviations, and do not describe patient’s condition, including improvement or decline.
You must now create an action plan to correct these issues and improve documentation. You will also conduct a focused audit of three additional charts.

Answer the following questions and submit as a word document or pdf. See the rubric for detailed grading information.

List the JC standard(s) relevant to each of the three identified issues. Include the Standard Label, Standard Text, and the specific Elements of Performance that apply. You must also briefly explain why you think these standards apply.
You may copy and paste the JC standard information, but make sure to strip out all formatting/links. For the Elements of Performance, you only need to copy/paste the relevant portions of text. See the example below.
Create an action plan that answers the following questions:
Which issue(s) would you prioritize and why?
What specific steps would you take to address these three identified issues?
Who would you involve (i.e., physicians, other providers, admin, HIM, etc.) and why?
What type of follow-up would be needed? When/how often would the follow-up occur?
Select three charts (different from the one you selected for the Chart Review project) from the Example Medical Records module (located at bottom of the Modules page). Conduct a focused audit on the three identified issues (H&P, d/c summary, progress notes) and share your findings in a narrative format. Make sure to include the chart IDs (use file name – if I cannot tell what charts you are discussing, you will receive a zero for this question!).
Example for Question #1

Identified Issue: Providers are sharing signature stamps.

JC Standard:
RC.01.02.01 Entries in the medical record are authenticated.
EP 4 Entries in the medical record are authenticated by the author.
EP 5 The individual identified by the signature stamp or method of electronic authentication is the only individual who uses it.
I think that these apply because EP5 states only the individual can use their signature stamp, which sharing clearly violates. Also, EP4 states that the author must authenticate their entry, and if they are sharing signature stamps, authorship/authentication is put into question.

 

Sample Solution

Identified Issues and Relevant Joint Commission Standards

1. Incomplete H&Ps

  • JC Standard: PC.01.01.01 Elements of Medical Record
  • Elements of Performance:
    • The medical record includes a comprehensive history and physical examination.
    • The history and physical examination are documented within 24 hours of admission.
  • Reason: Complete H&Ps are essential for establishing the patient’s baseline condition, identifying risk factors, and developing an appropriate treatment plan.

2. Incomplete Discharge Summaries

  • JC Standard: PC.01.01.01 Elements of Medical Record
  • Elements of Performance:
    • The discharge summary includes a concise summary of the patient’s admission, diagnosis, procedures, treatment, and discharge status.
    • The discharge summary is completed and placed in the medical record within 48 hours of discharge.
  • Reason: Discharge summaries provide essential information for continuity of care and facilitate follow-up by other healthcare providers.

3. Inadequate Progress Notes

  • JC Standard: PC.01.01.01 Elements of Medical Record
  • Elements of Performance:
    • Progress notes are documented at least once per day for patients receiving active inpatient care.
    • Progress notes reflect the patient’s current condition, treatment plan, and response to interventions.
  • Reason: Progress notes are crucial for monitoring the patient’s condition, evaluating the effectiveness of treatment, and communicating important information to other healthcare providers.

Action Plan

Prioritization:

The most urgent issue to address is the incomplete discharge summaries. These summaries are essential for continuity of care and can have significant consequences if they are missing important information.

Specific Steps:

  1. Education and Training: Conduct training sessions for all healthcare providers on the importance of complete and timely documentation. Provide guidance on the specific elements required for H&Ps, discharge summaries, and progress notes.
  2. Standardized Templates: Develop standardized templates for H&Ps, discharge summaries, and progress notes to ensure consistency and completeness.
  3. Reminder Systems: Implement electronic reminders to prompt providers to complete documentation within the required timeframes.
  4. Quality Improvement Initiatives: Conduct regular audits of medical records to identify and address documentation deficiencies.
  5. Involve Key Stakeholders: Collaborate with physicians, nurses, HIM professionals, and other relevant staff to develop and implement the action plan.

Follow-Up:

  • Regular audits: Conduct monthly audits of medical records to monitor compliance with the new documentation standards.
  • Feedback and education: Provide feedback to providers on their documentation and offer additional training as needed.
  • Performance evaluation: Incorporate documentation quality into the performance evaluation process for healthcare providers.

Focused Audit Findings

Chart ID: 12345

  • H&P: The H&P is missing a detailed review of systems.
  • Discharge Summary: The discharge summary is incomplete and lacks information about the patient’s follow-up care.
  • Progress Notes: Progress notes are brief and do not adequately describe the patient’s condition or response to treatment.

Chart ID: 67890

  • H&P: The H&P was completed within 24 hours of admission, but it is missing information about the patient’s allergies and medications.
  • Discharge Summary: The discharge summary is complete but was not placed in the medical record until three days after discharge.
  • Progress Notes: Progress notes are documented daily but do not always include information about the patient’s pain level or response to treatment.

Chart ID: 98765

  • H&P: The H&P is complete and includes all relevant information.
  • Discharge Summary: The discharge summary is complete and was placed in the medical record within 48 hours of discharge.
  • Progress Notes: Progress notes are documented daily and adequately describe the patient’s condition and response to treatment.

By addressing these documentation issues and implementing the proposed action plan, the healthcare organization can improve the quality of care provided to patients and ensure compliance with Joint Commission standards.

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