Accreditation Audit free essay sample

Executive Summary Nightingale Community Hospital prides itself on their values, such as safety, community, teamwork and accountability. Yet, we now understand the more has to be done to provide a safer place for our patients. Nationwide, hospitals are trying to find innovative ways to provide safer care and less complication for their employees. Establishing and encouraging standard practices within the infrastructure of the hospital will reduce chances of human error. With so many physician and staff working at different hospitals and healthcare facilities, variations among these facilities with medical records can result in error and frustration for caregivers. This also brings about a hospital burden because of having to educate, train and provide resources for their own unique facility and policies. Timely medical record documentation and monitoring will help lower this risk and keep the hospital in compliance. Documenting medical records in a timely fashion is an important standard in the Joint commission accreditation process. We will write a custom essay sample on Accreditation Audit or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page It requires an accredited hospital to have a have a written policy facilitating the timely documentation into the medical records. Great patient care must have timely completion of medical records. Errors can and will occur if records are not complete and accurate. Not to mention, the patients health could be at jeopardy. Delinquent medical records policy Nightingale Community Hospital has revised our delinquent medical records policy for physicians and staff in accordance with Joint Commission requirements. The medical records department will closely monitor all records for errors and delinquencies and implement the following steps: 1. Medical record delinquencies must be completed within 30 days from discharge or physicians/staff will receive a certified letter stating a â€Å"hold† has been placed on their scheduling of admissions and/or procedures. The â€Å"hold† will not be lifted until completion of all errors and delinquencies on medical records. A hold means a physician: ) cannot have any elective patient admissions and/or schedule any elective invasive procedures. b) can refer to Nightingale Community Hospital any outpatient diagnostics that do not require him/her to perform the procedure. c) is required to make arrangements to follow his/her current inpatients until discharge. 2. Delinquent medical records must be completed by the Friday before or names will be turned in for suspension of clinical privileges. Each physician will receive a certified letter indicat ing the suspension. If the suspension lasts for more than 30 days, Nightingale Hospital is required to report this adverse action to the National Practitioner Data Bank. 3. Departments such as Admissions, Managerial Nurses, Surgery, Directors and other medical staff, will be notified of physicians that are placed on â€Å"hold† or suspended lists. The lists will be updated as changes occur. Author Unknown (2011). Delinquent Medical Records. Houston Medical Journal, Retrieved August 8, 2011, from http://www. montgomerycollege. edu/library/citinginternet. pdf