MANAGEMENT AFFILIATION - part 2

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Release of Info Reports (ROI)

HIT 226 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 2014
Date Received Client Name Requestor Name Info Disclosed Purpose of Disclosure Date Disclosed Records Offsite Staff ID # Completion Time Standard Compliance
1 1/1/14 Jones, Johnny PCP H & P Continuity of Care 1/21/14 N 14571 20 30 10
2 1/4/14 King, Samantha St. Lawrence D/C Summary Continuity of Care 1/17/14 N 14571 13 30 17
3 1/5/14 Piazza, Anthony PCP D/C Summary Continuity of Care 2/8/14 N 25148 34 30 -4
4 1/9/14 Legend, Mary Attorney D/C Summary Litigation 3/3/14 Y 25148 53 60 7
5 1/10/14 Stepnowski, Joseph Robert Wood Johnson X-rays Continuity of Care 1/14/14 N 25148 4 30 26
6 1/11/14 Largent, Khalif Mother D/C Summary At the request of the individual 2/28/14 N 14571 48 30 -18
7 1/11/14 Williams, Michael PCP H & P Continuity of Care 1/17/14 N 14571 6 30 24
8 1/15/14 Teller, Aiden PCP D/C Summary Continuity of Care 1/20/14 N 25148 5 30 25
9 1/17/14 Hower, Layla Bayonne Medical Center D/C Summary Continuity of Care 2/26/14 N 14571 40 30 -10
10 1/18/14 Cartwright, Renee Robert Wood Johnson Lab reports Continuity of Care 2/1/14 Y 14571 14 60 46
11 1/20/14 Perez, Stacey PCP X-rays Continuity of Care 3/5/14 Y 25148 44 60 16
12 1/21/14 Santoso, Susan Attorney X-rays Litigation 3/1/14 N 14571 39 30 -9
13 1/21/14 Williams, William St. Lawrence D/C Summary Continuity of Care 1/28/14 N 14571 7 30 23
14 1/21/14 Abrams, Jonah St. Lawrence D/C Summary Continuity of Care 4/5/14 N 25148 74 30 -44
15 1/25/14 Stern, Kimberly Robert Wood Johnson H & P Continuity of Care 1/31/14 N 25148 6 30 24
16 1/25/14 Sran, Timothy PCP Lab reports Continuity of Care 2/5/14 N 25148 11 30 19
17 1/27/14 Berger, Mark PCP X-rays Continuity of Care 2/9/14 N 25148 13 30 17
18 1/28/14 Romano, Maria Attorney D/C Summary Litigation 2/1/14 N 14571 4 30 26
19 1/31/14 Smith, Jennifer St. Lukes D/C Summary Continuity of Care 3/3/14 N 14571 31 30 -1
20 1/31/14 Martinez, Alonso PCP D/C Summary Continuity of Care 5/4/14 Y 25148 93 60 -33
Release of Information
Compliance 65%
On Time 13
Total 20

Record Completion (PO)

HIT 226 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 2014
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 # of Days Standard Compliance Date of Order Date Signed # of Days Standard Compliance Date of Order Date Signed # of Days Standard Compliance Date of Order Date Signed # of Days Standard Compliance Date of Order Date Signed # of Days Standard Compliance
1/6/14 1/6/14 0 1 1 1/7/14 1/9/14 2 1 -1 1/10/14 1/10/14 0 1 1 1/18/14 1/21/14 3 1 -2 1/28/14 1/28/14 0 1 1
1/6/14 1/6/14 0 1 1 1/7/14 1/9/14 2 1 -1 1/10/14 1/10/14 0 1 1 1/18/14 1/21/14 3 1 -2 1/28/14 1/28/14 0 1 1
1/6/14 1/7/14 1 1 0 1/7/14 1/9/14 2 1 -1 1/10/14 1/10/14 0 1 1 1/18/14 1/21/14 3 1 -2 1/28/14 1/28/14 0 1 1
1/7/14 1/7/14 0 1 1 1/7/14 1/9/14 2 1 -1 1/10/14 1/11/14 1 1 0 1/29/14 1/29/14 0 1 1
1/7/14 1/7/14 0 1 1 1/8/14 1/9/14 1 1 0 1/11/14 1/11/14 0 1 1 Compliance 0% 1/30/14 1/30/14 0 1 1
1/8/14 1/8/14 0 1 1 1/8/14 1/9/14 1 1 0 1/12/14 1/13/14 1 1 0 On Time 0 1/30/14 1/30/14 0 1 1
1/9/14 1/10/14 1 1 0 1/9/14 1/9/14 0 1 1 1/12/14 1/13/14 1 1 0 Total 3 1/31/14 1/31/14 0 1 1
1/9/14 1/9/14 0 1 1 1/12/14 1/13/14 1 1 0 2/1/14 2/1/14 0 1 1
Compliance 100% 1/12/14 1/13/14 1 1 0 2/2/14 2/2/14 0 1 1
On Time 7 Compliance 50% 1/13/14 1/15/14 2 1 -1 2/2/14 2/2/14 0 1 1
Total 7 On Time 4 1/14/14 1/15/14 1 1 0
Total 8 1/15/14 1/15/14 0 1 1 Compliance 100%
On Time 10
Compliance 92% Total 10
On Time 11
Total 12

Record Completion (H & P)

HIT 226 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.
History and Physical Report for January 2014
MR # Physician Date of Admission Date Dictated Date Transcribed Date Signed # of days Standard Compliance # of days Standard Compliance
1 789321 Leiberman 1/4/14 1/4/14 1/4/14 1/5/14 0 1 1 1 1 0
2 456321 Huffman 1/4/14 1/5/14 1/5/14 1/5/14 0 1 1 1 1 0
3 741852 Patrikus 1/6/14 1/7/14 1/8/14 1/8/14 1 1 0 2 1 -1
4 963321 Johns 1/7/14 1/7/14 1/7/14 1/10/14 0 1 1 3 1 -2
5 144558 Huffman 1/10/14 1/10/14 1/11/14 1/11/14 1 1 0 1 1 0
6 695852 Leiberman 1/10/14 1/10/14 1/10/14 1/10/14 0 1 1 0 1 1
7 124536 Huffman 1/12/14 1/12/14 1/12/14 1/13/14 0 1 1 1 1 0
8 379152 Leiberman 1/15/14 1/16/14 1/16/14 1/16/14 0 1 1 1 1 0
9 685982 Jones 1/16/14 1/16/14 1/16/14 1/17/14 0 1 1 1 1 0
10 558844 Jones 1/17/14 1/17/14 1/17/14 1/18/14 0 1 1 1 1 0
11 415287 Johns 1/20/14 1/22/14 1/22/14 1/24/14 0 1 1 4 1 -3
12 919125 Patrikus 1/20/14 1/20/14 1/20/14 1/22/14 0 1 1 2 1 -1
13 744445 Patrikus 1/21/14 1/21/14 1/21/14 1/25/14 0 1 1 4 1 -3
14 111111 Patrikus 1/21/14 1/21/14 1/21/14 1/22/14 0 1 1 1 1 0
15 145281 Huffman 1/26/14 1/26/14 1/27/14 1/27/14 1 1 0 1 1 0
16 144417 Leiberman 1/26/14 1/26/14 1/26/14 1/27/14 0 1 1 1 1 0
17 695833 Patrikus 1/27/14 1/27/14 1/27/14 1/31/14 0 1 1 4 1 -3
18 335588 Johns 1/28/14 1/31/14 1/31/14 2/2/14 0 1 1 5 1 -4
19 457924 Jones 1/31/14 1/31/14 1/31/14 2/1/14 0 1 1 1 1 0
20 414519 Huffman 1/31/14 1/31/14 1/31/14 2/1/14 0 1 1 1 1 0
Dictation Transcription
Compliance 100% Compliance 65%
On Time 20 On Time 13
Total 20 Total 20

Record Completion (DC Summary)

HIT 226 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.
Discharge Summary Report for January 2014
MR # Physician Date of Discharge Date Dictated Date Transcribed Date Signed # of Days Standard Compliance # of days Standard Compliance
1 789321 Leiberman 1/7/14 2/1/14 2/1/14 2/15/14 25 30 5 39 30 -9
2 456321 Huffman 1/8/14 1/29/14 1/30/14 2/10/14 21 30 9 33 30 -3
3 741852 Patrikus 1/10/14 1/17/14 1/18/14 1/19/14 7 30 23 9 30 21
4 963321 Johns 1/28/14 2/8/14 2/8/14 2/10/14 11 30 19 13 30 17
5 144558 Huffman 1/12/14 1/29/14 1/29/14 2/28/14 17 30 13 47 30 -17
6 695852 Leiberman 1/11/14 1/31/14 1/31/14 2/12/14 20 30 10 32 30 -2
7 124536 Huffman 1/18/14 2/15/14 2/15/14 2/21/14 28 30 2 34 30 -4
8 379152 Leiberman 1/17/14 2/7/14 2/8/14 3/1/14 21 30 9 43 30 -13
9 685982 Jones 1/19/14 1/19/14 1/20/14 1/21/14 0 30 30 2 30 28
10 558844 Jones 1/18/14 1/25/14 1/25/14 1/28/14 7 30 23 10 30 20
11 415287 Johns 1/21/14 1/24/14 1/25/14 1/31/14 3 30 27 10 30 20
12 919125 Patrikus 1/26/14 1/31/14 2/1/14 2/15/14 5 30 25 20 30 10
13 744445 Patrikus 1/24/14 2/4/14 2/4/14 2/6/14 11 30 19 13 30 17
14 111111 Patrikus 1/23/14 1/26/14 1/26/14 1/31/14 3 30 27 8 30 22
15 145281 Huffman 1/28/14 1/31/14 1/31/14 3/8/14 3 30 27 39 30 -9
16 144417 Leiberman 1/31/14 2/28/14 2/28/14 3/4/14 28 30 2 32 30 -2
17 695833 Patrikus 2/1/14 2/15/14 2/15/14 2/21/14 14 30 16 20 30 10
18 335588 Johns 2/1/14 2/15/14 2/15/14 2/19/14 14 30 16 18 30 12
19 457924 Jones 2/10/14 2/10/14 2/11/14 2/12/14 0 30 30 2 30 28
20 414519 Huffman 2/6/14 2/7/14 2/7/14 4/1/14 1 30 29 54 30 -24
Dictation Signature
Compliance 100% Compliance 55%
On Time 20 On Time 11
Total 20 Total 20

Record Completion (OP Report)

HIT 226 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 2014
MR # Physician Date of Operation Date of discharge Date Dictated Date Transcribed Date Signed Dictation Completion Standard Compliance Signature Completion Standard Compliance
1 789321 Leiberman 1/4/14 1/6/14 1/4/14 1/4/14 1/7/14 0 1 1 3 30 27
2 456321 Huffman 1/5/14 1/6/14 1/5/14 1/5/14 1/6/14 0 1 1 1 30 29
3 741852 Patrikus 1/6/14 1/10/14 1/7/14 1/7/14 1/7/14 1 1 0 1 30 29
4 963321 Johns 1/8/14 1/10/14 1/8/14 1/8/14 1/8/14 0 1 1 0 30 30
5 144558 Huffman 1/10/14 1/15/14 1/10/14 1/10/14 1/11/14 0 1 1 1 30 29
6 695852 Leiberman 1/10/14 1/11/14 1/12/14 1/12/14 1/13/14 2 1 -1 3 30 27
7 124536 Huffman 1/13/14 1/16/14 1/13/14 1/13/14 1/14/14 0 1 1 1 30 29
8 379152 Leiberman 1/15/14 1/18/14 1/17/14 1/17/14 1/19/14 2 1 -1 4 30 26
9 685982 Jones 1/16/14 1/20/14 1/17/14 1/17/14 1/20/14 1 1 0 4 30 26
10 558844 Jones 1/18/14 1/25/14 1/20/14 1/20/14 1/27/14 2 1 -1 9 30 21
11 415287 Johns 1/21/14 1/23/14 1/22/14 1/22/14 1/22/14 1 1 0 1 30 29
12 919125 Patrikus 1/20/14 1/26/14 1/21/14 1/21/14 1/21/14 1 1 0 1 30 29
13 744445 Patrikus 1/22/14 1/23/14 1/22/14 1/22/14 1/23/14 0 1 1 1 30 29
14 111111 Patrikus 1/21/14 1/28/14 1/21/14 1/21/14 1/21/14 0 1 1 0 30 30
15 145281 Huffman 1/27/14 1/28/14 1/27/14 1/27/14 1/27/14 0 1 1 0 30 30
16 144417 Leiberman 1/26/14 1/30/14 1/31/14 1/31/14 2/2/14 5 1 -4 7 30 23
17 695833 Patrikus 1/28/14 1/30/14 1/28/14 1/28/14 1/29/14 0 1 1 1 30 29
18 335588 Johns 1/28/14 1/31/14 1/29/14 1/29/14 1/29/14 1 1 0 1 30 29
19 457924 Jones 1/31/14 2/5/14 1/31/14 1/31/14 2/10/14 0 1 1 10 30 20
20 414519 Huffman 2/1/14 2/3/14 2/1/14 2/1/14 2/2/14 0 1 1 1 30 29
Dictation Signature
Compliance 80% Compliance 100%
On Time 16 On Time 20
Total 20 Total 20

Incident Reports (IR)

HIT226 Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Analyze the data in terms of the 2014 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 2014
Type of incident Number of incidents Standard Compliance
Falls from bed 15 NPSG.06.01.01
Falls from toilet 8
Medication error 9
Allergic reaction 19 ***
Blood transfusion reaction 2
Hospital acquired infections 12 NPSG.07.01.01
Surgical errors 1

Core Measure

HIT226 Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Analyze the data to determine compliance with Core Measure requirements. Problem areas should be identified in relation to the national average and minimum expected and discussed in Part 2 of the Course Project. N/A - means that the data is not available due to not being collected. Minimum expected means that the hospital definitely needs to meet this requirement.
Core Measure Report for January 2014 - MI & CHF (Myocardial Infarction & Congestive Heart Failure)
Heart Attach Care General Hospital National average Minimum expected Heart Failure Care General Hospital National average Minimum expected
Average number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital 57 59 Heart Failure patients given discharge instructions 94% 94% 80%
Average number of minutes before outpatients with chest pain or possible heart attack got an ECG 9 7 Heart Failure patients given an evaluation of left ventricular systolic (LVS) function 100% 99% 80%
Outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival N/A 57% Heart Failure patients given an ACE inhibitor or ARB for left ventricular systolic dysfunction (LVSD) 95% 97% 80%
Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival 95% 96% 80%
Heart attack patients given fibrinolytic medication within 30 minutes of arrival N/A 58%
Heart attack patients given PCI within 90 minutes of arrival 94% 96% 80%

Meaningful Use

HIT 226 Course Project; Hospital Data Analysis and Reporting
The data below is from General Hospital. Analyze the data to determine compliance with Meaningful Use Requirements Stage 1 for Eligible Hospitals and discuss in Part 2 of the Course Project. Hint: Use Eligible Hospital and Critical Access Hospital (CAH) Attestation Worksheet for Stage 1 of the Medicare Electronic Health Record (EHR) Incentive Program, provided as a separate document in doc sharing.
Selected Meaningful Use Measures for January 2014
Selected Meaningful Use Measures General Hospital Standard Compliance
Percentage of patients that had at least one medication order entered through the CPOE 50% 30% Met
The eligible hospital or CAH has enabled the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period No Yes Not Met
Percentage of patients who had at least one entry (or an indication that the patient has no known medical allergies) recorded as structured data 50% 80% Not Met

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 TJC 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