The following is the result of the evaluation of NCH’s medication management and medication safety program. 1. Joint Commission Standard MM.01.01.01 The first standard reviewed for compliance was MM.01.01.01 which determines if a hospital medication management processes are planned and coordinated among the various disciplines and services to maintain an environment of quality and safety. Furthermore, there must be written documentation in place to demonstrate compliance (Joint Commission, 20015). Compliance Status: The above standard has been met as observed by the evaluation of the Patient Specific Information policy.
Its Primary purpose is to ensure quality patient care and managing the cost of that care. Its secondary purpose as defined by the Institute of Medicine (IOM) deals with individual users for education, regulations, policies and public health from data entered, verified, corrected or analyzed directly or indirectly. Homeland Security has recently been added to the list of users, including patient care providers, managers and staff, coders and patients themselves. Patients can make changes as necessary. Other users might include lawyers, employers, law enforcement and researchers.
Joint Commission has laid out a strategic and detailed set of expectations that hospitals and other healthcare organizations can use to ensure they are in compliance with health laws. At Nightingale we seem to be in compliance with a number of these standards. According to a recent periodic performance review we are in compliance with the Joint Commission standards in the Emergency Management requirement section. The EM develops a plan in case the facility has an emergency that includes the planning of activities of hospital administrators and leaders. This plan should include details that would identify what an emergency is, how it would be communicated to the staff, and what arrangements will be made for the facility.
The Importance of Proper Chart Documentation Introduction One of the most important things you will do in your job in the healthcare profession is charting. Charting is the way healthcare professionals communicate a patient’s weight, height, condition, medication, and past medical history. As soon as you walk in a doctor’s office, hospital, or any medical facility charting begins from the moment you sign in. Only healthcare professionals that are certified, licensed, or registered to chart should do so. There are three reasons proper chart documentations are important: to avoid lawsuits, keep accurate medical information for patient, and to maintain proper communication from one professional to another.
How to Review a Surgical Day Care Patient’s Chart. • Take OR booking package, a pre-op checklist and a nursing telephone check list slip. • Fill out as much information as you can from the OR booking chart onto the pre -op checklist • If questions begin to formulate during the chart audit, write them on the telephone check list slip so when you speak to patient on the phone you do not forget to ask. (remember this is a nursing working copy and does not become part of the chart, if something is important it MUST be written on the pre op check list or a nurses notes sheet. • Remember to transcribe as much needed information as you can over to the pre op checklist, as OR needs the charts the day before to have an anaesthetic review the chart.
The EHR is a computerized electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates the clinician's workflow and has the ability to generate a complete record of a patient encounter - as well as supporting other care-related activities directly or indirectly, including evidence-based decision support, quality management, and outcome reporting. In this paper I will discuss the many benefits and drawbacks of EHR’s, the types of software used and their functions as well as my thoughts on the future of Electronic Health Records. Many healthcare organizations have switched over to electronic health records since President George W. Bush called for health records to be stored electronically by 2014, and President Obama’s administration plans to continue pushing for that deadline.
These statistics represent individual people who have their own needs, but share the common need for their healthcare professional to provide expert care to them during their time in hospital. Castledine (2004) tells us that all nurses should carry out a patient assessment automatically as this is the first stage in ascertaining the health of the patient. A past medical history should be obtained and a physical assessment made as
2 H.C.A’s know which medicines each person has and the social care service keeps a complete account of medicines. Medicine records are essential in every social care service. If you look after medicines for the people you care for, at any given time you should be able to identify the medicines prescribed for each person and how much they have left. Even when H.C.A’s do not routinely give medicines, it is
Confidentiality, integrity and availability of computerised patient information. Within this assignment I am going to explain the meaning of confidentiality, integrity, and availability in relation to the management of electronic patient records with in the NHS. These terms and their enforcement are imperative to patient record management. I will demonstrate via a scenario how easy it is to breach or lose patient information and these vital aspects of record management. For the purpose of patient safety (NMC 2009), and data protection all names and locations have been changed or omitted to maintain anonymity in accordance with the Data Protection act (1998).
WHAT IS AN ELECTRONIC MEDICAL RECORD (EMR) ? An Electronic Medical Record (EMR) is a way of storing patient information on a computer. EMR have a similar structure to the paper-charts, and these contain all the information that is relevent for the treatment and nursing of a patient. The EMR includes both clinical information: such as diagnosis, allergies and medicines; and a demographic information, such as: personal information, for non-clinical use- an example of such information is the patients’ health number that is given to him/her when he/she visits the hospital for the first time. The records contain information that is used for different purposes: 1) Administrative tasks: Registering patients Scheduling appointments 2) Clinical practices (diagnostic & therapeutic decisions): Computerized prescriptions Lab tests Diagnostic measures Progress notes from different healthcare providers 3) Research practices QUALITY BENEFITS OF AN EMR Assessing data from paper medical records is time-consuming because it involves reviewing information manually — record by record.