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.

 

Sample Solution

Action Plan to Improve Documentation Compliance

Joint Commission Standards

  1. History and Physical Examinations
  • Standard: PC.02.01.01
  • Standard Text: The medical record includes a complete and accurate history and physical examination (H&P) for each patient.
  • Elements of Performance:
    • The H&P is performed within 24 hours of admission or before surgery, whichever is earlier.
    • The H&P includes the patient’s chief complaint, present illness, past medical history, family history, social history, review of systems, and physical examination.
  1. Discharge Summaries
  • Standard: PC.02.03.01
  • Standard Text: The medical record includes a complete and accurate discharge summary for each patient.
  • Elements of Performance:
    • The discharge summary is completed within 24 hours of discharge.
    • The discharge summary includes the patient’s admitting diagnosis, course of treatment, final diagnosis, disposition, and follow-up instructions.
  1. Progress Notes
  • Standard: PC.02.04.01
  • Standard Text: The medical record includes complete and accurate progress notes for each patient.
  • Elements of Performance:
    • Progress notes are documented at least daily or more frequently as indicated by the patient’s condition.
    • Progress notes include the patient’s condition, treatment provided, and response to treatment.
    • Progress notes are legible and avoid the use of abbreviations that are not on the Joint Commission’s approved list.

Action Plan

Prioritization:

The most critical issue to address is the incomplete and untimely discharge summaries. Incomplete discharge summaries can lead to medication errors, adverse events, and delays in follow-up care.

Specific Steps:

  1. Education and Training: Conduct mandatory training sessions for all providers on the importance of complete and timely documentation. Provide guidance on how to complete H&Ps, discharge summaries, and progress notes according to Joint Commission standards.
  2. Template Development: Develop standardized templates for H&Ps, discharge summaries, and progress notes to ensure consistency and completeness.
  3. Audit and Feedback: Conduct regular audits of medical records to identify documentation deficiencies. Provide feedback to providers and offer support to help them improve their documentation skills.
  4. Technology Implementation: Explore the use of electronic health records (EHRs) or other technology tools to streamline documentation processes and improve accuracy.
  5. Incentives and Consequences: Implement incentives for providers who consistently meet documentation standards and consequences for those who do not.

Involvement:

Involve the following individuals in the implementation of the action plan:

  • Physicians: Educate physicians about the importance of complete and accurate documentation and provide them with tools and resources to support their efforts.
  • Other Providers: Train other healthcare providers, such as nurses and therapists, on documentation requirements and best practices.
  • HIM Staff: Collaborate with HIM staff to develop standardized templates, conduct audits, and provide feedback to providers.
  • Administration: Obtain administrative support for the implementation of the action plan, including allocating resources and ensuring accountability.

Follow-Up:

  • Regular audits: Conduct monthly audits of medical records to monitor progress and identify areas for improvement.
  • Feedback and support: Provide ongoing feedback and support to providers to help them maintain compliance with documentation standards.
  • Evaluation: Evaluate the effectiveness of the action plan and make adjustments as needed.

Focused Audit Findings

Chart ID 1: Patient 12345

  • H&P: The H&P is complete, but it was not performed within 24 hours of admission.
  • Discharge Summary: The discharge summary is missing the patient’s follow-up instructions.
  • Progress Notes: Progress notes are brief and use prohibited abbreviations.

Chart ID 2: Patient 67890

  • H&P: The H&P is complete and timely, but the review of systems is incomplete.
  • Discharge Summary: The discharge summary is complete and timely.
  • Progress Notes: Progress notes are complete and legible, but they do not describe the patient’s condition in detail.

Chart ID 3: Patient 45678

  • H&P: The H&P is complete and timely, but the family history is missing.
  • Discharge Summary: The discharge summary is complete and timely, but the patient’s medications are not listed accurately.
  • Progress Notes: Progress notes are complete and legible, but they do not document the patient’s response to treatment.

By addressing these documentation issues, Sacred Heart Hospital can improve the quality of patient care and reduce the risk of adverse events.

 

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