Rasmussen College Delinquent Record Statistics Paper

User Generated

pxvat424

Health Medical

Rasmussen University

Description

Scenario

For the purpose of this assignment, assume that you are the manager of the HIM Department of General Hospital. The hospital is due for a Joint Commission accreditation survey in six months. The CEO has asked for a report regarding medical staff compliance with Joint Commission requirements for delinquent records last year.

Information Regarding Joint Commission Standards

The following are Joint Commission standards that address timeliness of medical record completion.

Information Regarding General Hospital's Policies, Procedures, Rules, and Regulations

To implement this standard, General Hospital's policies and procedures state:

  • The medical record delinquency rates are monitored on a monthly basis;
  • Action will be taken when a problem is indicated; and
  • Data will be available to demonstrate improvement.

In addition, to ensure the timely entry of all significant clinical information into the patient's record, the Medical Staff Rules and Regulations list the following documentation requirements:

  • The total number of delinquent records may not exceed 50% of the total number of inpatient discharges and ambulatory surgeries performed for the month.
  • The total number of delinquent history and physicals may not exceed 2% of the total number of inpatient discharges and ambulatory surgeries performed for the month.
  • The total number of delinquent operative reports may not exceed 2% of the total number of inpatient operations and ambulatory surgeries.

Assignment Instructions

Download this Delinquent Record Report and use the data it contains to complete the following:

Part-1: Create Delinquent Record Report Table

  1. Using Microsoft Excel, input the data from the Delinquent Record Report. Include report, column and row titles, and the monthly data.
  2. Use Excel to calculate and automatically insert the total number of discharges for the month.
    1. Total discharges = total inpatient discharges + total ambulatory surgeries.
    2. Total operations = total ambulatory surgeries + total inpatient operations.
  3. Use Excel to calculate and insert the number of delinquent records, history and physical exam reports (H & Ps), and operative reports permitted according the Medical Staff Bylaws for each month in 20XX based on the hospital's statistics for that month. To calculate the year's figure, the monthly average should be used. Therefore, have a final monthly average column and use Excel to compute the averages for all rows.

Part-2: Create Line and Bar Graphs

  1. Using Microsoft Excel, construct both line graphs and bar graphs showing the following:
    1. The hospital's actual delinquent records compared to the total number of delinquent records permitted by the Medical Staff Rules and Regulations for the 12 months in 20XX (do not include the total for the year)
    2. The hospital's actual delinquent H & Ps compared to the total number of delinquent H & Ps permitted by the Medical Staff Rules and Regulations for the 12 months in 20XX (do not include the total for the year).
    3. The hospital's actual delinquent ORs compared to the total number of delinquent ORs permitted by the Medical Staff Rules and Regulations for the 12 months in 20XX (do not include the total for the year).

Part-3: Write Narrative Analysis

  1. In a Word document, provide a narrative analysis of the findings for the CEO.
    1. Reference the table and use the graphs you prefer to illustrate compliance in the report.
    2. Include in the analysis whether the hospital was in compliance with the Medical Staff Rules and Regulations in each of the three areas during each month of the year.
    3. Was the hospital in compliance for the whole year?
    4. Be sure your analysis is free of spelling and grammar errors.

Submit the following to your instructor:

  1. Delinquent Record Report Table
  2. Line and bar graphs
  3. Narrative analysis of findings

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Explanation & Answer

Here is the final work. Please check it. In case of anything, please let me know. All in all, the work is well done. Pleasure working with you.

Delinquent Records
The medical staff was not compliant to the joint commission standards that address the
timeliness of the completion of medical records, especially in the areas of history and physical
exam reports and operative reports. From the table and the graph, the medical staff was
compliant in the field of delinquent records, as shown in figure 1. The staff was compliant
throughout the year with the number of the actual delinquent records submitted being lower than
the number of the permitted delinquent records for all the months.

ACTUAL DELINQUENT RECORDS VS. DELINQUENT
RECORDS PERMITTED
1200
1000
800
600
400
200
0
1

2

3

4

5

ACTUAL DELINQUENT RECORDS

6

7

8

9

10

11

12

13

# OF DELINQUENT RECORDS PERMITTED

Fig. 1

Delinquent history and physical exam reports
In the field of history and physical exam reports, the medical staff was compliant for
most of the months of the year. From the graph below, the month that the medical staff was not
compliant with the joint commission standards was November. The number of the actual

d...


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