Accreditation Audit, AFT2, Task 1

A. Compliance Status (Quality Improvement, Expertise and Activities)
The Nightingale Joint Commission report addresses some areas that need improvement and indicates a lack of communication and knowledge of written policies in place. The use of abbreviations in the medical record, number of incidents of misidentified patient specimens and the intake sheet used when a patient enters the hospital. The report shows that Nightingale is in compliance in the above areas but highlights the areas for improvement. The Nightingale report fails to show how information on a patient is gathered, received and stored. For Nightingale Hospital to be compliant with Joint commission standards, the patient record needs to accurate. The findings show a breakdown in communication as in one example, failure to document reevaluation of a patient was not noted.
The Joint Commission Survey report outlines the need for consistency in the intake/screening process. The hospital has not shared the registration and or collection of information process with providers as indicated in the survey report. Providers need to be aware of the intake process to ensure all information has been collected so a good representation of the client is available which allows the providers to spend time asking follow up questions. The provider needs access to patient history, patient family history, current medication and past aliments to properly assist a patient.
After reviewing the Joint Commission survey report, areas of training are needed so providers know how to accurately document the patient medical record. Policy needs to be in place so documentation is clear, no use of abbreviations in notes and documentation so patient care is consistent. Survey report indicates that in once incident, a patients’ reevaluation was not documented. The Joint Commission requires procedures in place to maintain an accurate patient medical record.
A1. Plan for Compliance
(Joint Commission Standard…