The priority area I would be focusing my corrective action plan on is information management. I chose to review the Information Management area of Nightingale hospital because I believe in a hospital or any healthcare facility for that matter, proper documentation, communication, transfer, and interpretation of information is essential in the continuum of care.
Carefully examining Nightingale’s admission order, it is fully in compliance. There is no use of prohibited abbreviation, commonly mistaken abbreviations are terms were avoided, and were spelt out in full.
Nightingale uses standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations (Joint Commission on Accreditation of Healthcare Organizations, 2015). Another document that included NPSG data stated otherwise. It showed that at different points in time, Nightingale used some of the prohibited abbreviation and our goal is for the hospital to be 100% in compliance. The administrator or whoever is in charge is responsible for reeducating members of his/her staff on the importance of 100% compliance and making sure that none of the prohibited abbreviations or terms are being used, and making sure that once there is a compliance issue it is immediately addressed.
For Joint Commission Standard RC 01.01.01 which was to make sure that the hospital maintains complete and accurate medical records for each individual patient, I was unable to find any medical records. I find it hard to believe that a hospital does not keep or have any form of medical records. Since I can’t find any medical record, I will say that this is a compliance issue and it is very important that Nightingale not only maintains a medical record, but one that is complete and accurate for each individual patient.
Joint Commission Standard RC 01.04.01 states that the hospital audits its medical records. There is no evidence of a medical record based on information provided and there also isn’t any...