Patient Health Record and Review of Record: Joint Commission Standards and Expectations

Patient Health Record and Review of Record

Task:

Special Note: Before you begin, be sure to make the revisions to Milestones One and Two by incorporating all of the instructor’s feedback. Once you have revised your first two milestones, then copy/paste them into this document. From there, you will add the information for the last phase of the project, which includes the sections titled “Secondary Data Sources” and “Conclusions and Recommendations”.

Document Format: Margins are one inch on all sides. All text in the document should be double-spaced. The font is 12-point Times New Roman. The title page is page 1.
Running Head: The running head is an abbreviated title of the paper, located at the top of each page. It identifies the manuscript or published article for readers. The running head should consist of no more than 50 characters, including all letters, punctuation, and spaces. The words Running head appear only on the title page and are omitted from all subsequent pages in the document. All letters in the running head title are UPPERCASE.

Patient Health Record and Review of Record

In this section, you will identify the following information in the patient’s chart: Family History, Procedure, Surgeon, Anesthesia and Medications. 1–2 paragraphs should be sufficient.

Joint Commission Standards and Expectations

Identify the Data

In this section, you will identify the data routinely reviewed by TJC for compliance with RC standards.

Missing Data

In this section, you will evaluate where the record is complete and where it is missing data.

Deficient

In this section, you will Outlines the TJC standards where the hospital is deficient, based on the missing data, and describes impact of violated standards.

Systems and Technology

Data Collection and Storage

In this section, you will discuss how the hospital is currently collecting patient data.  Review the scenario provided to determine current data collection methods.

Gaps or Issues

In this section, you will address the gaps/issues with the current systems/technology.  Address what is not working well for the organization and what could be improved. 

Recommendations

In this section, you will make recommendations for how the organization can improve upon current systems/technology. Secondary Data Sources

In this section, you will explain how secondary data sources are derived (where is the information obtained?), and how local and national registries are created using this secondary data.

Data Elements

In this section, you will evaluate what type of policy would ensure the required data elements are present in the patient record for data collecting registry purposes.

Recommendations

In this section, you will refer back to the audit of the medical health record in Milestone One. You will provide a detailed assessment of what data elements are required for compliance with TJC’s IM and RC standards.