While studying the surgical patient tracer worksheet, one of the most serious deficiencies identified was the patient history and physical not being done within twenty-four hours of admission. In fact, the patient medical records were completed after more than seventy-two hours of patient admission. Documenting medical records in an appropriate time frame is an important standard in the joint commission accreditation process. The Joint Commission requires an accredited hospital to have written policies regarding timely documentation into medical records. Eighty percent of a patient’s diagnosis is done by the identification of their current and past medical histories.
Missy Drake MEDS 1551 09-07-2013 Review Exercises 1) In patient is when one is admitted into the hospital for at least 24 hours to receive extended medical care. Outpatient is where one receives a diagnostic evaluation and or treatment from a particular department of a hospital without staying a 24-hour period. 2) The basic four consist of History and Physical Report, Discharge Summary, Operative Note or Report, and Consultation report. The only thing that is different form the basic four that the basic six has is the Pathology Report and Radiology Report. 3) Four methods of physical examination would evaluation performed by the physician or health profession would be Visual, auditory or aural, olfactory, and tactile.
All patients referred in to the trust must be treated within eighteen weeks of referral. Patients who are referred in to the trust due to a suspicion of cancer must be treated within sixty-two days if they are diagnosed. The trust faces financial penalties if these targets are not met. 2. Explain the organisation’s mission and purpose Mid Yorkshire Hospital’s mission and purpose is to provide medical care to the community in acute and specialist health circumstances to the Wakefield and Kirklees areas.
Physician/Practitioner Name: John Black, MD | | | | | | Physician/Practitioner ID Number: | | | | | | | | | | | | | | Patient Full Name: Beth Long | | Medical Record Number: | | | Patient DOB: 12/17/xx | | | | | | | | | | | | | | | | | Admission Date:04/26/xx | | | Discharge Date: 04/30/xx | | | | | | | | | | | | | Analyzed By: John Black, MD | | | | | | | | Date of Analysis: 4/30/XX | | | | | | | | | | | | | | | | | | | | | Deficiencies | | | | | | | | | | | | | | Signatures Missing | | | Missing or Inadequate Reports and/or | | | | | | Dictation Required | | | | | | | | | | | ______ | History & Physical | | | | ______ | History & Physical | | | __X____ | Consultation | | | ______ | Consultation | | ______ | Admission/Readmission Report | ______ | Admission/Readmission Report
Joanne Alexander was scheduled to have a surgical procedure at Orthopaedics of Indianapolis with Dr Kevin Scheid M.D. Patients over the age of 60 are required to have a chest x-ray done before any surgical procedures due to possible anesthesia issues. Mrs. Alexander, age 62 was x-rayed on the 24th of June; the Radiologist reading her x-ray report noted a “density” in the right upper lobe of her right lung reported and sent a hard copy of the report to Dr. Sheids office which was placed in her file apparently without notice of the radiology recommendation of comparison with previous x-rays. The plaintiffs maintain that they were not told of any problems or irregularities on the June 24th x-ray. 10 months later, in the spring of 1994 distressing symptoms brought Mrs. Alexander to a different doctor.
The beginning of a treatment plan for Jean can read as the following: Problem/Symptom: Jean has neglected to see a medical doctor | Long Term Goal: Jean to get a physical examination. | Short Term Goals/Objectives: 1. Jean to obtain medical coverage if she doesn’t have it 2. Jean to make an appointment to see the medical doctor 3. Jean to attend all medical appointments outlined by the physician | Date Established 10/4/1110/4/1110/4/11 | Projected Completion Date 1-2-12 1-2-12 1-2-12 | | Intervention/Action Counselor to make necessary referrals and follow-up during individual counseling sessions on a weekly basis.
WGU Accreditation Audit RAFT Task 2: Root Cause Analysis of a sentinel event A Root Cause Analysis (RCA) of a sentinel event is completed to immediately investigate and respond to possible inductions involving the death or injury of a patient. (Joint commission, 2013). Purpose of this report - To execute a Root Cause Analysis for a Sentinel Event occurrence at Nightingale Hospital. Sentinel Event - Child Abduction Date of Issue/Incident – Thursday September 14, at 12:30 PM Background of Issue/Incident - A three year old female patient was brought to Nightingale Hospital by her mother for an outpatient surgical procedure. The mother asked the pre-op nurse how long the procedure would take, because she had to tend to another child and would need to leave for a short while.
TASK D Ipswich Hospital Criticised for Care of the Elderly In March 2011 Ipswich Hospital was visited by the Care Quality Commission. They reported that they had some “moderate Concerns” about the care provided by staff in two particular wards, for the elderly at the hospital. One of the areas of concern by the CQC was regarding “respecting and involving people who use services” They noted that patients names were on display on boards, so all visitors were able to see every patients details. It also stated that the elderly on the 2 wards were toileted on a commode in their bed area and not taken to a bathroom area. Patients were not given the option to get dressed, and that they were left in nightwear all day.
| d. | The patient will hand carry the requisition to the Radiology department. | e. | When Epic and RIS systems go back up, DO NOT RE-ENTER RADIOLOGY ORDERS IN THE SYSTEM. | | | * Faxing Prescriptions and Refills (RightFax Application Down) Staffing Requirements After 0 hours | After 24 hours | After 36 hours | After 72 hours | 0 Additional Staff | 0 Additional Staff | 0 Additional Staff | 0 Additional Staff
A medical journal entry by Merrifield, Battle and Powe, explains the results of a study done at Gwinnett Medical Center emergency department (ED) in 2001. It was estimated that patients could average 6 to 12 hours lying on back boards while waiting for physician and radiological clearance at this facility. The ED/ICU staff wanted to see if it was possible to assess a patient immediately upon arrival to the ED by an RN to determine if a patient was able to be taken off of the LSB. Their goal was to maintain C-spine alignment and spinal immobilization on the hospital bed, and off of the LSB. This was an attempt to minimize those additional injuries.