Accreditation Audit - Task 1

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DMK Accreditation Audit Task 1 Current Compliance Status of Nightingale Community Hospital: Nightingale Community Hospital needs to bring several area up to Joint Commission standards. One area is in Information Management. Regarding the prohibited medical abbreviations, currently Nightingale Community Hospital is at 99.6% compliant. This must be increased to 100% compliance. The key regulations we will be addressing are: Joint Commission IM. 02.02.01: The hospital effectively manages the collection of health information. ID 3: The hospital follows its list of prohibited abbreviations, acronyms, symbols, and dose designations. Joint Commission RC. 01.01.01: The hospital maintains complete and accurate medical records for each individual patient. ID 8: The medical record contains information about the patient’s care, treatment, or services that promotes continuity of care among providers Joint commission RC. 01.04.01: The hospital audits its medical records. At this time, there is no significant protocol for correcting this problem. The current policy states the abbreviations are discouraged, but there is no protocol in place on how to monitor, educate, and correct such entries into patient’s medical charts. Without developing a plan to implement the protocol, Nightingale Community Hospital will not meet Joint Commission standards. Corrective Action Plan: 1) Provide all prescribing providers, nursing supervisors, nursing staff, medical records department, pharmacy department, radiology department, respiratory therapy department, and physical therapy department of the list of prohibited abbreviations. a. This list would be sent via interdepartmental and extra departmental memos, e-mails, or US Postal Service. b. The list of prohibited abbreviations will be posted in every nursing station, every patient chart, and

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