Accreditation Audit Study
Executive Summary
At Nightingale Community Hospital, our vision is to be the hospital of choice for patients and mission is to create a healing environment, with a passionate commitment to healthcare excellence. Joint Commission gives us guidelines and standards in order for us to keep providing quality care alongside with our values in safety, community, teamwork, and accountability.
As more hospitals choose to keep the medical records electronically, patients’ charts are becoming more and more accessible. However, there are so many medical abbreviations and they vary by the hospital systems, the physician groups, and so on. This causes confusion in treating patients, and So I will be reviewing how compliant Nightingale Community Hospital is on information management and also suggesting corrective action plan on the areas we need improvement to meet the Joint Commission Standards.
Compliance
The section that I would like to focus on is Nightingale Community Hospital’s medical information management. This correlates with the Joint Commission Standards:
1. NPSG. 01.01.01 - Use at least two patient identifiers when providing care, treatment, and services.
2. NPSG. 02. 02. 01 – Standardized Do Not Use List.
Reviewing the policy documents, I could not identify any guideline on patient verification. At any hospital, patients need to be identified correctly because it is connected to get the right patient, the right diagnosis, and the right treatments. It would be the best to place the policy on using patient identifications according to the Joint Commission Standards.
I evaluated the ‘Do Not Use’ list placed in Nightingale Community Hospital, and the list has very useful but incomplete. I also reviewed a blank copy of the admission order and found several abbreviations that could be misleading or confusing were used. This also concerns patient safety because it directs the correct treatments for the patients....