Diane has found that there are several deficiencies on policies addressing information management. The policies need revisions and updating to ensure organizational readiness for the upcoming visit of the Joint Commission (JC).
1. The policy addressing terminology and abbreviations needs an update; also she does not know who will be responsible of performing the task and disseminate the information across the hospital. The hospital might not in fully compliance of the following Joint Commission Standard:
a. IM.02.02.01 – Collection of Health Information, which states that the hospital needs a uniform data set to standardize data collection. (Joint Commission, 2010) Also, a written policy which includes terminology, definitions, abbreviations, …show more content…
Creation of new staff positions for auditing of health records, and formalized the new position of a clinical documentation specialist. The hospital might not in fully compliance of the following Joint Commission Standard:
a. IM.01.01.01 – Information Management Planning, which states that the hospital identifies the internal and external information require for safe and effective health care. (Joint Commission, 2010) Also, the monitoring the hospital data information. In addition, standard require the hospital to have a committee of licensed independent practitioners which will participate in the assessment, selection, integration, and use of information management systems. (Joint Commission, 2010)
i. Diane needs to propose to her supervisor and the Board of Directors the creation of staff positions for the process of auditing medical records. Also, the formalization and hiring of the clinical documentation specialist. Once hire, the clinical documentation specialist, will help with the update of policies such as, the one addressing terminologies and abbreviations. In addition, will he/she will ensure that the information is disseminate to all areas and by the most effective way at Willow bend and within the shortest time possible. (Kathleen M. LaTour,