JC - You are the HIM Director at Sacred Heart Hospital

JC

Scenario: You are the HIM Director at Sacred Heart Hospital. You have been asked to report on the authentication of the medical record at the next Quality Improvement meeting. To prepare for your presentation, you conduct an audit of a sampling of records and uncover some glaring issues.

1. Physician verbal orders and progress notes are not consistently dated, timed, and authenticated.

2. Some nurse practitioners without privileges are documenting in the medical records on behalf of their physician employers.

3. There is a large backlog of discharge summaries, so a project was initiated in which nurses are paid to dictate summaries to clear the backlog. The summaries are signed by the Medical Director.

4. Finally, while this was not discovered in the audit, you recall rumors that clinical staff often share credentials.

Directions:

Download and complete the provided  template  Download template . For each issue, you need to identify and summarize relevant Joint Commission standards (using the eDition) https://edition.jcrinc.com/ProxyLogin.aspx?lnk=f0475d880a4c&PID=2

E-dition - Standards & EPs (jcrinc.com) and identify the responsible party/parties that will be in charge of ensuring each standard is followed. 

1. JC Chapter and Standards

· Issues may have more than one relevant standard. Your standards must be drawn from at least three different chapters (for example, you cannot solely use the Medical Staff chapter or the Record of Care, Treatment, and Services chapter for all four issues). Make sure to include the full chapter name, the standard number, and the standard text. Example: Information Management - IM.01.01.01 The hospital plans for managing information.

2. Summary of Standard and EP

· You need to summarize the standard and relevant EPs in your own words. Remember that this is for a report - your summary should be professional, concise, and clear. You may use a maximum of two direct quotes (1-2 sentences each). Direct quotes need to be cited in APA format. Copy/pasting from the EPs without a citation is considered plagiarism. 

3. Responsible Party

· Identify a responsible party or parties for each standard (remember, HIM does not create the Medical Staff Rules and Regulations, but we are often tasked with enforcing them!).

4. Example for Question #1

5. Identified Issue: Providers are sharing signature stamps.

6. JC Standard: RC.01.02.01 Entries in the medical record are authenticated. EP 4 Entries in the medical record are authenticated by the author. EP 5 The individual identified by the signature stamp or method of electronic authentication is the only individual who uses it. I think that these apply because EP5 states only the individual can use their signature stamp, which sharing clearly violates. Also, EP4 states that the author must authenticate their entry, and if they are sharing signature stamps, authorship/authentication is put into question.