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Health Information Management - Final
Project
Southern New Hampshire
University
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Health Information Management - Final Project
Health records are important for a multitude of reasons; the most important being
that quality patient care is delivered. Accuracy, timeliness and completeness are the essential
characteristics of a well-generated health record. Many different components comprise a
thorough and complete health record. All of these various components are subject to
accreditation standards by the Joint Commission. In order to meet these standards and
expectations certain data elements must be included.
Analysis of Health Record
Understanding patient health data elements is necessary in order to analyze the
information found in health record. History of present illness is a description of the present
illness as it developed. This section of a health record would include when symptoms first
presented along with whether they have decreased or increased in severity. This section
should also include any underlying condition that may be contributing to the patients’
symptoms.
Relevant information about the illness that might cause complications to another organ
system, predisposing conditions and potential diagnoses that have already been excluded
should all be documented. In the health record that I reviewed this section was included
but was lacking. The author failed to note the sex and age of the patient. Another concern
is that the author did not elaborate on the past procedure now resulting in complications,
nor did he clarify what treatments had been used thus far.
Family medical history is vital information for a healthcare provider to have.
Reviewing a patients’ family history can help inform the diagnosis of a patient. This section
should include any diseases and conditions that a patient’s blood relatives have been
diagnosed with and is usually found in the form for history and physical exam. In the
health record that I reviewed for
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Pam Ray, family history was documented though it was not thorough. In the case of family
history, authors of this data can only chart what information the patient provides. Review
of systems like the aforementioned data elements can also be found in the history and
physical exam form. This data element is defined as being an inventory of the body
systems and their condition. This data is included in Pam Rays’ record, but it includes only
four organ systems, though a description of every organ system is not necessarily required
given the circumstances of the patients’ present symptoms and history.
In addition to being able to define data elements, a person must also know what
information is required for complete and accurate data. For recording the admission
diagnosis, the section should include the diagnosis established by the attending physician
upon the patients’ admission to the hospital. An operative report should include the name of
patient; the date of the procedure, the name of surgeon that performed the operation, a
description of the procedure performed both post and pre-operative diagnoses, a pathology
report when applicable, and any findings during surgery. When recording discharge
instructions there should be the reason for discharge, a summary of the patients’ diagnosis
and treatment, instruction for diet, physical activity, and medications, any referrals and
follow-up appointments and procedures, and information about the patients’ current
condition.
Joint Commission Standards and
Expectations Identify the Data and Connection with Joint
Commission Standards
The Joint Commission has standards in place for data collected by any healthcare
facility or organization. In order to obtain accreditation status the organization must be
found to comply with these standards. The Joint Commission has standards for collecting
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and documenting data,
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as well as managing it. A hospital such as Global Care Medical Center is required to have
systems in place to ensure the accuracy and security of information. For example, the
standard for effectively managing the collection of health information is IM.02.02.01. This
standard establishes that the hospital must use standardized terminology, abbreviations,
definitions, acronyms, symbols, and dose designations. ("The Joint Commission E-dition ",
2019). In the chart for Pam Ray, I was unable to identify failures to comply with standards
of information management.
Missing Data and Connection with Joint Commission Standards
The Joint Commission has clearly defined standards of what data must be included in
a health record. In the health record for Pam Ray that I reviewed there were several data
elements missing from her chart. Joint Commission standard RC.01.01.01 dictates that all
entries in the health record are both timed and dates. There were several entries throughout
the chart that were missing either the time, date, or both. Pam Ray’s health record was
missing demographic information such as complete date of birth; also, it was missing from
the inpatient face sheet whether or not she has any known allergies. This puts Global Care
Medical Center in violation of Joint Commission standard RC.02.01.01. ("The Joint
Commission E-dition ", 2019)
There are physician signatures missing from the record, which is failure to comply
with standard RC. 01.02.01. Failure to comply with Joint Commission standards was also
found in the lack of any insurance information, which is in noncompliance with
RC.01.01.01. ("The Joint Commission E-dition ", 2019). Data missing from health records
can lead to disruption of care for the patient and loss of accreditation for a healthcare
facility.
Deficient Data and Connection with Joint Commission Standards
A health record might sometimes be missing required data or the data may be
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deficient.
In order to comply with the Joint Commissions accreditation standards, data must be
complete and accurate. In the health record for Pam Ray, data is deficient in the discharge
instructions, where a follow up is ordered but no further details are provided. This
deficiency fails to comply with Joint Commission standard RC.02.01.01. Global Care
Medical Center fails again to comply with this same standard by missing complete
demographic are for the patients’ next of kin. This standard is not met again where as a
complete date of birth is missing for the patient, day and month are present but year is
absent. ("The Joint Commission E-dition ", 2019)
The advanced directive is not only missing patient initials but has the wrong patient
name, which is out of regulation with RC. 02.01.01. In the operative report, there is lacking
information about the patients’ vital signs and level of consciousness. Also missing from the
operative report are total time of operation, the name of the anesthesiologist, and other
relevant details such as findings during the procedure, specimens removed and medications
administered. This is out of compliance with Joint Commission standard RC.02.01.03. ("The
Joint Commission E-dition ", 2019). Global Care Medical Center must implement a plan to
address and correct these deficiencies or risk losing accreditation status.
Systems and Technology
Data Collection
New England North Hospital currently collects and stores data via manual entry,
utilizing workstations on wheels. In order to enter the health record the clinician must
manually enter the
patients’ medical record number from the patients’ armband. The workstations are located
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at all clinical locations and are connected wirelessly to the main server. The hospitals’
server is kept within the hospital in an air-conditioned protected room with generators in
case of power failure. The healthcare information manager is looking to transition to
automated data storage and collection methods.
Gaps and Issues
The hospital utilizes generators to power the server should there be a power failure;
however, there is no back up in place in the case of a fire or natural disaster, Joint
Commission standard IM.01.01.03 dictates that a hospital must plan for continuity of its
information management. This standard also applies to the workstations on wheels since
they need to be charged between uses, this could result in lost data or even clinicians
being unable to access patient data. Standard IM.02.01.01 requires the hospital to protect
the privacy of health information, this is concerning since clinicians will sometimes write
down patient information such as vital signs and chart them later. This runs the risk of the
information being lost or accidently left where it is visible to unauthorized individuals, as
well as the possibility of the clinician forgetting to chart the findings in a timely manner
or forgetting to chart them entirely. Clinicians accessing the health record via manually
entering the patients’ medical record number is also an issue, just as there are technical
glitches there is also human error that could lead to information being attributed to the
wrong patient in violation of standard IM.02.01.03. (The Joint Commission E-dition”,
2009).
Functionality
Implementing automated systems such as barcode readers and automatic data capture
would help to streamline data entry and help protect patient privacy. While having data stored
on site has its advantages, there are drawbacks as well. I would definitely investigate if any
fortifications can be made to the room where the data center is located to further prevent
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damage
should vents such as a fire or flood occur. In addition to adding further protection to the
onsite data center, I would recommend having a backup off site or utilizing a cloud server.
My preference would be for the cloud server, though I would move to cloud computing
exclusively. (Beaty, "Cloud Computing 101", 2013).
Secondary Data Sources
Secondary data are derived from primary data sources; primary data is that which
is obtained first-hand for a specific purpose. If a health information management
professional creating a health record gathered such information as race and sex from a
patient, this would be an example of primary data. If a registrar then accessed that health
record to collect the previously documented data for the creation of a new registry, this
would be secondary data.
Once all primary data is collected from the original source, it can be categorized into
registries. Registries themselves are considered to be secondary databases, some examples
include the organ donor registry, Alzheimer’s’ prevention registry, and cancer registries.
(“How Cancer Registries Work/CDC”, 2019), (Gliklich, “Data Sources for Registries”,
2019).
Data Elements
Cancer registries are one of the most common examples of how registries can play
an important role in healthcare. In order to build a thorough and efficient cancer registry,
there are certain data elements it is required to contain. Patient name (first, middle, last),
social security number, date of birth, sex, and current address are all required in a cancer
registry of any type ("Cancer Registry, NAACCR and data elements", 2019). Organizations
might have their own additional requirements depending on the specialty of the registry
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(type of cancer, survivorship, etc.). Of course, sensitive information such as social security
numbers would be protected from public consumption.
Conclusions and Recommendations
Data Required
The Joint Commission has standards and regulations that healthcare facilities must
comply with or else risk losing accreditation status. When creating or updating a patients’
health record, certain data elements are required to ensure completeness and accuracy. The
hospital must maintain complete and accurate medical records for each patient that it treats.
This includes documenting demographic information, information needed to support the
patients’ diagnosis and subsequent treatment, signed consent forms, and discharge
information. In addition to the health record containing specific data elements, all entries
must be timed, dated, signed by the author of the entry and must be legible. . (“The Joint
Commission E-dition”, 2019).
The Joint Commission also has standards for maintaining and storing health records.
Hospitals must routinely audit their records and retain them for a length of time in
accordance with state laws. Hospitals are required to plan for ensuring privacy of protected
health information, as well as planning to preserve data in circumstances of damage or
power failures. (“The Joint Commission E-dition”, 2019). These aforementioned regulations
as well as others help to preserve the integrity of healthcare data management.
Organization’s Compliance
In the health record for Pam Ray that I referenced above, there were some
standards that Global Care Medical Center failed to meet. The patients’ correct age must be
listed and date of birth documented on every page pursuant to TJC standard RC.02.01.01.
The patients’ day and month of birth are listed on every page but the year is missing, this
in turn calls into question the
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accuracy of her noted age. TJC standard RC.01.01.01 requires that all entries in the health
record
are dated and timed stamped, there were several pages in Ms. Rays’ chart that were
missing the date and/or time. On Ms. Rays’ inpatient face sheet and her discharge summary
there was missing the physician signature, this is in violation of TJC standard RC.01.02.01.
(“The Joint Commission E-dition”, 2019). The regulations not only exist to protect the
patient but to protect the healthcare organization from legal action.
Registry Compliance
In 1992 congress passed the Cancer Registries Amendment Act, this led to the creation of
the National Program of Cancer Registries (NPCR), which is administered by the Centers for
Disease Control and Prevention (CDC). ("About NPCR | Cancer | CDC"). This resulted in
the development of uniform standards for the quality and completeness of data collected
and reported to cancer registries. Data that must be reported to registries include demographic
information about each case of cancer, occupation of the patient, the date of diagnosis, as well
as pathological information, which includes but is not limited to type of cancer, site of
cancer, stage of cancer, incidence, and treatment provided. ("Centers for Disease Control and
Prevention ")
The health record for Pam Ray lists her occupation as well as her demographic information.
The patient is not a cancer patient, therefore her health record would not contain the
required data needed for a cancer registry. Ms. Rays’ health record is not compliant with the
Joint Commission standards previously referenced. This would then call into question the
integrity of her health record for use in a cancer registry. (“The Joint Commission E-dition”,
2019).
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Recommendations
In any large healthcare organization responsible for the collection, documenting, and storage
of data there are bound to be mistakes made. These seemingly inconsequential mistakes
however can have serious legal ramifications to the organization in question, as well as to
patient care.
In order to reduce the likelihood of mistakes New England North Hospital first needs to
ensure all staff is properly trained. In addition to initial training of new hires, yearly
competency tests should be instituted to ensure all employees are knowledgeable of all laws,
regulations, and standards. The hospital should also draft policies requiring that all data
entry be complete and documented within a specified timeframe. The health information
department could also routinely audit patient health records to note errors. If a pattern
emerges such as demographic information frequently being missing or deficient, this could
be addressed on a department level to the admitting staff.Transitioning from manual data
entry to automated data would also be a step towards preventing data from being lost and
its entry delayed. Once issues concerning data collection and entry are addressed and
resolved, data storage then must be improved. I would recommend that they continue to
store data on premise, but with extra precautions in place to protect their data. Their central
server is kept in a power conditioned room and utilizes generators in case of a power
failure, however there aren’t any fortifications in preparation of a fire or flood. In addition to
extra safety measures for their on-site storage, they should have a secondary source of their
data kept at a remote location. Though unlikely data at both locations could be destroyed
due to unforeseen events such as natural disasters or gas explosions. Utilizing cloud
computing in their data retention plan would add a subsequent level of security.
Conclusion
New England North Hospital is lacking in the area of health information
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management. I found several errors in the health record for Pam Ray, as well as weaknesses
in their methods for collecting, entering, and storing data. In any large health organization
that treats a large volume of patients, the amount of data that needs to be collected and
managed can seem daunting.
The process of addressing every Joint Commission violation and holding every staff
member accountable has no simple solutions. If however, New England North Hospital
wishes to maintain its accreditation status, they must adapt their policies and procedures to
assure they are in compliance with TJC standards.
The health information manager at New England Hospital has expressed concern
for some of the same issues that I addressed. If a plan is formulated to make the
necessary changes that I have suggested it would greatly benefit New England North
Hospital. This is an investment in the future of New England North Hospital.
Implementing these changes will protect New England North Hospital from loss of
accreditation, legal action, and injury to its reputation as a quality healthcare facility.
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References
About NPCR | Cancer | CDC. (n.d.). Retrieved April 12,2021, from
https://www.cdc.gov/cancer/npcr/about.htm
AHIMA's Long-Term Care Health Information Practice and Documentation Guidelines.
Practice
Guidelines for LTC Health Information and Record Systems Indexes and Registries.
(n.d.). Retrieved April 12,2021, from http://bok.ahima.org/Pages/Long Term Care
Guidelines TOC/Practice Guidelines/Indexes
Beaty, D. L. (2013). Cloud Computing 101. Retrieved April 12,2021, from
https://eds-a-ebscohost-com.ezproxy.snhu.edu/eds/detail/detail?vid=0&sid=27f77eca
Cancer Registry, NAACCR and data elements. (n.d.). Retrieved April 12,2021, from
https://www.ibm.com/support/knowledgecenter/en/SS9NBR
Centers for Disease Control and Prevention. (n.d.). Retrieved April 12,2021, from
https://www.cdc.gov/cancer/npcr/npcrpdfs/publaw.pdf
Gliklich, R. E. (n.d.). Data Sources for Registries. Retrieved April 12,2021, from
https://www.ncbi.nlm.nih.gov/books/NBK208611/
HITInfrastructure. (2018, May 24). Data Demands Call for Increased Healthcare Storage
Flexibility. Retrieved April 12,2021, from https://hitinfrastructure.com/news/data-
demands-call-for-increased-healthcare-storage-flexibility
How Cancer Registries Work | CDC. (n.d.). Retrieved April 12,2021, from
https://www.cdc.gov/cancer/npcr/value/registries.htm
The Joint Commission E-dition. (n.d.). Retrieved April 12,2021, from
https://www.jointcommission.org/
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McWay, D. C., JD, RHIA. (2014). Today’s health information management: An integrated
approach (second Ed.). Clifton Park, NY: Delmar/Cengage Learning.
USCS Data Visualizations. (n.d.). Retrieved April 12,2021,
from https://gis.cdc.gov/Cancer/USCS/DataViz.html
Where Should Healthcare Data Be Stored In 2018 - And Beyond? (n.d.). Retrieved April
12,2021
, from https://www.healthitoutcomes.com/doc/where-should-healthcare-data-be-
stored-in-and-beyond-0001
