MANAGEMENT AFFILIATION

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Release of Info Reports (ROI)

Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with the Release of Information Standards. Areas of noncompliance should be identified as well as the standard. Hint: You may use your own state's Department of Health standards in addition to HIPAA requirements.
Release of Information Report for January
Date Received Client Name Requestor Name Info Disclosed Purpose of Disclosure Date Disclosed Records Offsite Staff ID #
1 1/1/14 Jones, Johnny PCP H & P Continuity of Care 1/21/14 N 14571
2 1/4/14 King, Samantha St. Lawrence D/C Summary Continuity of Care 1/17/14 N 14571
3 1/5/14 Piazza, Anthony PCP D/C Summary Continuity of Care 2/8/14 N 25148
4 1/9/14 Legend, Mary Attorney D/C Summary Litigation 3/3/14 Y 25148
5 1/10/14 Stepnowski, Joseph Robert Wood Johnson X-rays Continuity of Care 1/14/14 N 25148
6 1/11/14 Largent, Khalif Mother D/C Summary At the request of the individual 2/28/14 N 14571
7 1/11/14 Williams, Michael PCP H & P Continuity of Care 1/17/14 N 14571
8 1/15/14 Teller, Aiden PCP D/C Summary Continuity of Care 1/20/14 N 25148
9 1/17/14 Hower, Layla Bayonne Medical Center D/C Summary Continuity of Care 2/26/14 N 14571
10 1/18/14 Cartwright, Renee Robert Wood Johnson Lab reports Continuity of Care 2/1/14 Y 14571
11 1/20/14 Perez, Stacey PCP X-rays Continuity of Care 3/5/14 Y 25148
12 1/21/14 Santoso, Susan Attorney X-rays Litigation 3/1/14 N 14571
13 1/21/14 Williams, William St. Lawrence D/C Summary Continuity of Care 1/28/14 N 14571
14 1/21/14 Abrams, Jonah St. Lawrence D/C Summary Continuity of Care 4/5/14 N 25148
15 1/25/14 Stern, Kimberly Robert Wood Johnson H & P Continuity of Care 1/31/14 N 25148
16 1/25/14 Sran, Timothy PCP Lab reports Continuity of Care 2/5/14 N 25148
17 1/27/14 Berger, Mark PCP X-rays Continuity of Care 2/9/14 N 25148
18 1/28/14 Romano, Maria Attorney D/C Summary Litigation 2/1/14 N 14571
19 1/31/14 Smith, Jennifer St. Lukes D/C Summary Continuity of Care 3/3/14 N 14571
20 1/31/14 Martinez, Alonso PCP D/C Summary Continuity of Care 5/4/14 Y 25148

Record Completion (PO)

Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state's Department of Health standards.
Physician Order Report for January
Physician : Dr. Jones Physician: Dr. Johns Physicians: Dr. Huffman Physician: Dr. Patrikus Physician: Dr. Leiberman
Client Medical Record #: 123456 Client Medical Record #: 987654 Client Medical Record #: 654789 Client Medical Record #: 321789 Client Medical Record #: 741852
Date of Admission: 1/6/14 Date of Admission: 1/7/14 Date of Admission: 1/10/14 Date of Admission: 1/18/14 Date of Admission: 1/28/14
Date of Discharge: 1/9/14 Date of Discharge: 1/9/14 Date of Discharge: 1/15/14 Date of Discharge: 1/18/14 Date of Discharge: 2/2/14
Date of Order Date Signed Date of Order Date Signed Date of Order Date Signed Date of Order Date Signed Date of Order Date Signed
1/6/14 1/6/14 1/7/14 1/9/14 1/10/14 1/10/14 1/18/14 1/21/14 1/28/14 1/28/14
1/6/14 1/6/14 1/7/14 1/9/14 1/10/14 1/10/14 1/18/14 1/21/14 1/28/14 1/28/14
1/6/14 1/7/14 1/7/14 1/9/14 1/10/14 1/10/14 1/18/14 1/21/14 1/28/14 1/28/14
1/7/14 1/7/14 1/7/14 1/9/14 1/10/14 1/11/14 1/29/14 1/29/14
1/7/14 1/7/14 1/8/14 1/9/14 1/11/14 1/11/14 1/30/14 1/30/14
1/8/14 1/8/14 1/8/14 1/9/14 1/12/14 1/13/14 1/30/14 1/30/14
1/9/14 1/10/14 1/9/14 1/9/14 1/12/14 1/13/14 1/31/14 1/31/14
1/9/14 1/9/14 1/12/14 1/13/14 2/1/14 2/1/14
1/12/14 1/13/14 2/2/14 2/2/14
1/13/14 1/15/14 2/2/14 2/2/14
1/14/14 1/15/14
1/15/14 1/15/14

Record Completion (H & P)

Course Project - Data Analysis and Identification of Noncompliance
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state's Department of Health standards.
History and Physical Report for January
MR # Physician Date of Admission Date Dictated Date Transcribed Date Signed
1 789321 Leiberman 1/4/14 1/4/14 1/4/14 1/5/14
2 456321 Huffman 1/4/14 1/5/14 1/5/14 1/5/14
3 741852 Patrikus 1/6/14 1/7/14 1/8/14 1/8/14
4 963321 Johns 1/7/14 1/7/14 1/7/14 1/10/14
5 144558 Huffman 1/10/14 1/10/14 1/11/14 1/11/14
6 695852 Leiberman 1/10/14 1/10/14 1/10/14 1/10/14
7 124536 Huffman 1/12/14 1/12/14 1/12/14 1/13/14
8 379152 Leiberman 1/15/14 1/16/14 1/16/14 1/16/14
9 685982 Jones 1/16/14 1/16/14 1/16/14 1/17/14
10 558844 Jones 1/17/14 1/17/14 1/17/14 1/18/14
11 415287 Johns 1/20/14 1/22/14 1/22/14 1/24/14
12 919125 Patrikus 1/20/14 1/20/14 1/20/14 1/22/14
13 744445 Patrikus 1/21/14 1/21/14 1/21/14 1/25/14
14 111111 Patrikus 1/21/14 1/21/14 1/21/14 1/22/14
15 145281 Huffman 1/26/14 1/26/14 1/27/14 1/27/14
16 144417 Leiberman 1/26/14 1/26/14 1/26/14 1/27/14
17 695833 Patrikus 1/27/14 1/27/14 1/27/14 1/31/14
18 335588 Johns 1/28/14 1/31/14 1/31/14 2/2/14
19 457924 Jones 1/31/14 1/31/14 1/31/14 2/1/14
20 414519 Huffman 1/31/14 1/31/14 1/31/14 2/1/14

Record Completion (DC Summary)

Course Project - Data Analysis and Identification of Noncompliance
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state's Department of Health standards.
Discharge Summary Report for January
MR # Physician Date of Discharge Date Dictated Date Transcribed Date Signed
1 789321 Leiberman 1/7/14 2/1/14 2/1/14 2/15/14
2 456321 Huffman 1/8/14 1/29/14 1/30/14 2/10/14
3 741852 Patrikus 1/10/14 1/17/14 1/18/14 1/19/14
4 963321 Johns 1/28/14 2/8/14 2/8/14 2/10/14
5 144558 Huffman 1/12/14 1/29/14 1/29/14 2/28/14
6 695852 Leiberman 1/11/14 1/31/14 1/31/14 2/12/14
7 124536 Huffman 1/18/14 2/15/14 2/15/14 2/21/14
8 379152 Leiberman 1/17/14 2/7/14 2/8/14 3/1/14
9 685982 Jones 1/19/14 1/19/14 1/20/14 1/21/14
10 558844 Jones 1/18/14 1/25/14 1/25/14 1/28/14
11 415287 Johns 1/21/14 1/24/14 1/25/14 1/31/14
12 919125 Patrikus 1/26/14 1/31/14 2/1/14 2/15/14
13 744445 Patrikus 1/24/14 2/4/14 2/4/14 2/6/14
14 111111 Patrikus 1/23/14 1/26/14 1/26/14 1/31/14
15 145281 Huffman 1/28/14 1/31/14 1/31/14 3/8/14
16 144417 Leiberman 1/31/14 2/28/14 2/28/14 3/4/14
17 695833 Patrikus 2/1/14 2/15/14 2/15/14 2/21/14
18 335588 Johns 2/1/14 2/15/14 2/15/14 2/19/14
19 457924 Jones 2/10/14 2/10/14 2/11/14 2/12/14
20 414519 Huffman 2/6/14 2/7/14 2/7/14 4/1/14

Record Completion (OP Report)

Course Project - Data Analysis and Identification of Noncompliance - Due in Week 6, day 7 (Sunday midnight)
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state's Department of Health standards.
Operative Report for January
MR # Physician Date of Operation Date of discharge Date Dictated Date Transcribed Date Signed
1 789321 Leiberman 1/4/14 1/6/14 1/4/14 1/4/14 1/7/14
2 456321 Huffman 1/5/14 1/6/14 1/5/14 1/5/14 1/6/14
3 741852 Patrikus 1/6/14 1/10/14 1/7/14 1/7/14 1/7/14
4 963321 Johns 1/8/14 1/10/14 1/8/14 1/8/14 1/8/14
5 144558 Huffman 1/10/14 1/15/14 1/10/14 1/10/14 1/11/14
6 695852 Leiberman 1/10/14 1/11/14 1/12/14 1/12/14 1/13/14
7 124536 Huffman 1/13/14 1/16/14 1/13/14 1/13/14 1/14/14
8 379152 Leiberman 1/15/14 1/18/14 1/17/14 1/17/14 1/19/14
9 685982 Jones 1/16/14 1/20/14 1/17/14 1/17/14 1/20/14
10 558844 Jones 1/18/14 1/25/14 1/20/14 1/20/14 1/27/14
11 415287 Johns 1/21/14 1/23/14 1/22/14 1/22/14 1/22/14
12 919125 Patrikus 1/20/14 1/26/14 1/21/14 1/21/14 1/21/14
13 744445 Patrikus 1/22/14 1/23/14 1/22/14 1/22/14 1/23/14
14 111111 Patrikus 1/21/14 1/28/14 1/21/14 1/21/14 1/21/14
15 145281 Huffman 1/27/14 1/28/14 1/27/14 1/27/14 1/27/14
16 144417 Leiberman 1/26/14 1/30/14 1/31/14 1/31/14 2/2/14
17 695833 Patrikus 1/28/14 1/30/14 1/28/14 1/28/14 1/29/14
18 335588 Johns 1/28/14 1/31/14 1/29/14 1/29/14 1/29/14
19 457924 Jones 1/31/14 2/5/14 1/31/14 1/31/14 2/10/14
20 414519 Huffman 2/1/14 2/3/14 2/1/14 2/1/14 2/2/14

Incident Reports (IR)

Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Analyze the data in terms of the 2020 Hospital National Patient Safety Goals, by The Joint Commission. Identify three areas for improvement that the hospital should focus on during February and discuss in Part 2 of the Course Project.
Incident Report for January
Type of incident Number of incidents
Falls from bed 15
Falls from toilet 8
Medication error 9
Allergic reaction 19
Blood transfusion reaction 2
Hospital acquired infections 12
Surgical errors 1

Standards

Standard list based on CMS & The Joint Commission Guidelines and requirements
Activity Standard Notes
Release of information for records stored onsite 30 days Needed for Part I of the project
Release of information for records stored offsite 60 days Needed for Part I of the project
Signing physician orders 24 hours Needed for Part I of the project
Dictating History and Physical 24 hours from admission (1 day) Needed for Part I of the project
Transcribing History and Physical * 24 hours from dictation date (1 day) Needed for Part I of the project * This is a hospital policy, not a CMS or JC standard
Dictating Discharge Summary 30 days from D/C date Needed for Part I of the project
Signing Discharge Summary 30 days from D/C date Needed for Part I of the project
Dictating Operative Report 24 hours from surgery (1 day) Needed for Part I of the project
Signing Operative Report 30 days from D/C date Needed for Part I of the project
Incident report Identify standard in the NPSG - separate document These are needed for Part II of the project
Core Measures Minimum expected and national average are provided in the spreadsheet These are needed for Part II of the project
Meaningful Use Standards provided in the Hospital Attestation Stage 1 Worksheet - separate document Needed for Part I of the project

Rubric

Grading Rubric for Part I
Calculations 5 points for each type of calculation (40 pts total)
ROI - days to release
PO - signature
H & P - dictation
H & P - transcription
D/C - dictation
D/C - signature
OP - dication
OP - signature
Subtotal 0
Standards 5 points each for matching and identifying the following standards (15 points total):
ROI, H&P, OP, & D/C
Meaningful Use (MU Stage 1) - Percentage of patients that had at least one medication order entered through the CPOE
Meaningful Use (MU Stage 1) - Percentage of patients who had at least one entry recorded as structured data
Subtotal 0
Compliance Rates 5 points each (30 pts total)
ROI
PO
H & P
D/C
OP
Meaningful Use
Subtotal 0
total (85 possible) 0