In: Nursing
With the invention of new technologies & processes today’s health care system has become more complex & different from what it used to be. American health care system has witnessed big changes in term of its delivery, quality & reach. Electronic health records have gained a lot of attention in today’s health care system due to its effectiveness in managing patient records & its efficiency.
The purpose of our survey is to assess that our hospital’s internal data dictionary requirements are in compliance with Joint Commission standards. Joint commission standards sets patient focused performance measures which are organized around functions & processes. The Comprehensive Accreditation Manual for Hospitals (CAMH) published by joint commission has functional data standards which are necessary to provide care. Hospitals are required to collect & submit data to joint commission.
During a joint commission survey of any health care organizations activity of tracers is important which covers most of the survey part. Tracers are done for many reasons like to evaluate the effectiveness of organizational policies & procedures, to check compliance with joint commission standards & national patient safety goals, staff competency, implementation of procedures etc.
Our focus is on data management system tracer to check hospital’s internal data dictionary requirements are in compliance with Joint Commission standards. We can survey the data management processes & systems on the basis of following points.
1) Documentation of data:
a) Does our hospital have continuous & consistent service of data documentation as required by joint commission standard?
b) Is the collection, storage & storing of data being done in an appropriate manner directed by JC?
2) Quality & efficiency of data:
a) Is the data easily accessible?
b) Can applications identify & maintain patient records, maintain documents & lists & generate medical records in a timely manner?
3) Privacy & security:
a) Is the process of security of data compliant with standards?
b) is the patient specific data safe & secure?