Question

As the HIM documentation supervisor, you are meeting with the quality improvement (QI) manager to assist in developing an audit template to be used for a quality review of patient record operative reports. Research the latest Joint Commission standard requirements to provide the QI manager for creating the template.

Develop a list of required data elements that would be applicable in development of an audit data collection tool for operative reports, inclusive of the time requirement for completion.

Answer 1

The key elements to design valuable clinical audits are:

1-choosing the topic,

2-defining a clear purpose and

3-providing the necessary organisation in terms of audit staff and resources

4-The first step that must be accomplished in designing a clinical audit is to identify the topic .

5-The topic of the audit can be loosely identified in clinical practice and may relate to the adequacy of a care process or that of the results

6-.An audited theme should have specific characteristics: it should be of great clinical importance, of easy collection and analysis, and source of important consequences.

7-The personnel involved in the audit have a key role in setting priorities among clinical problems to deal with.

8- Selection of indicators, criteria and standards and definition of intervention strategies also play a very important role in it

9-Data collection

In clinical audit data can be collected prospectively or retrospectively. Taking into consideration past clinical documentation, the latter method is certainly faster, but often the quality of the collected information is not optimal