Nightingale Community Hospital is expecting an audit from the Joint Commission in 13 months, and the areas of Information Management, Medication Management, Communication, and Infection Control all need to be addressed before the visit. The purpose of this executive summary is to review and outline the current state of compliance at Nightingale Community
Hospital in a specific priority focus area discussed below.
Information Management is one of the areas of focus for the Joint Commission visit, and it is being explored in depth in this summary. Here are the Joint Commission Standards in regards to the area of Information Management: IM.02.02.01
: The hospital effectively manages the collection of health information. A: Compliance Status Under the standard IM.02.02.01 in The Joint Commission E­dition, there are three elements of performance. One of these states “The hospital follows its list of prohibited abbreviations, acronyms, symbols, and dose designations” (The Joint Commission E­Dition).
While most of these elements of performance are being followed, Nightingale Community
Hospital is at 99.6% compliance for unacceptable abbreviations, and needs to strive to reach
100%.
From December to January, items that are on the list of unacceptable abbreviations were brought down to 0% in many cases, such as using the abbreviations “qd”, “x3d”, and “sc”.
However, from December to January, the use of the unacceptable term “u” (used to represent the word “unit”), rose from 17%, to 63%. A1: Plan for Compliance

In order for Nightingale Community Hospital to be at 100% compliance in this area, all hospital staff needs to be on the same page with what abbreviations are acceptable and which ones are not. To get all staff up to speed on this issue, an emailed memo should go out, briefly outlining all of the unacceptable abbreviations, and especially emphasizing the ones that are being used most frequently. Having these unacceptable terms posted where hospital staff can see them while taking notes will also help to get compliance to 100%. Lastly, it is important that all hospital staff keep their eyes open for errors, and bring it to another staff members attention if an unacceptable abbreviation has been used. A2: Justification Unacceptable abbreviations are an important section to be audited, because having discrepancies could lead to poor patient care and a negative outcome. For example, the abbreviation “x3d”, which is inappropriately used to show “for three days”, can often be mistaken for “three doses”. There is obviously a huge difference between three days and three doses, and a patient’s health is on the line when a mistake like this is made. By keeping the entire hospital on the same page with abbreviations, and being at 100% compliance, fewer mistakes will be made, and patient care will not be compromised. RC.01.01.01 hospital maintains complete and accurate medical records for each individual
: The patient. A: Compliance Status

The Joint Commission standard, RC.01.01.01, contains 13 sub­categories. One of these categories says, “The medical record contains information unique to the patient, which is used for patient identification” (The Joint Commission E­Dition). From a graph provided by
Nightingale Hospital, it shows that labeling errors went from 18 last year, to 42 this year; a 24 error difference. These errors occurred by using two different patient identifiers, and labeling specimens while the patient was present. A1: Plan for Compliance Labeling errors have been increasing at Nightingale Hospital over the past year. In order to bring these down to zero errors, and be in compliance with the Joint Commission, the hospital must set up a system where all patients are given only one patient identifier. For each patient, this should occur upon admission to the hospital. The hospital staff member who is in charge of taking vitals and admission information should set up the patient's identifier. If one person is in charge of this task, it is less likely for a patient to be identified two separate ways. Hospital staff who are running tests, and handling specimens from patients, must double­check their work to ensure that they have the correct patient identifier. A2: Justification Maintaining accurate medical records is a huge area of importance at a hospital. Patients come to the hospital to get a diagnosis for a problem, and some of these patients are previous visitors of the hospital who already have medical records on file. However, if these medical records are inaccurate, it could lead to severe consequences for the patient. Something as simple as not including an allergy on the medical records could lead to complications in patient

treatment, or even death. Labeling specimen cups with the proper patient identifier is also of utmost importance. If a sample were to be tested for a disease and/or infection, and the specimen was labeled incorrectly, the results could go back to the wrong patient. This could be very dangerous for both parties; the patient who actually is sick but has negative results from a mislabeled sample, as well as the patient who gets the positive results, and is potentially prescribed medication for something they don’t need. RC.01.04.01
: The hospital audits its medical records. A: Compliance Status From the information given by Nightingale Hospital, there is no way to know medical records are being audited, and if they are being audited in a way that is up to the Joint
Commission standard. It is required that the medical record delinquency rate is measured at regular intervals, and that time between these measures is no more than three months. There should be an ongoing review of timeliness, accuracy, presence, completeness of data and information, authentication, and legibility (for both printed or handwritten records) of the medical records (The Joint Commission E­Dition). A1: Plan for Compliance In order to keep in compliance with the Joint Commission, medical records must be audited regularly, and there must never be more than three months in between any one audit.
Reminders should be sent out to auditors two months after their most recent audit, so that they will not fall behind and out of compliance by taking more than three months between audits.
They need to continuously be checking for these six different categories during their audit;

completeness of data and information, timeliness, authentication, accuracy, presence, and legibility. For the area of legibility, auditors need to check both the computer generated and handwritten medical records. If the auditors at Nightingale Community Hospital can keep up to these standards, they should be in compliance when the Joint Commission visits in 13 months. A2: Justification Audits of medical records are performed to see what has already been done, and what the organization can work on doing better. By auditing records, Nightingale Hospital can more accurately see where it’s strengths and weaknesses are, and work on correcting them to make the hospital run smoothly and have less issues that could easily be fixed. Audits are important because in the long run, they save time and energy, and help the hospital from making expensive mistakes. References
The Joint Commission E­Dition. https://e­dition.jcrinc.com/MainContent.aspx 2016 The Joint
.
©
Commission, © 2016 Joint Commission Resources E­dition is a registered trademark of
The Joint Commission