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.

I am having troubles finding the latest Joint Commission standard requirements.

Answer 1

Joint Commission Standards are the basis of an objective evaluation process that can help health care organizations measure,assess and improve performance.The standards focus on important patient,individual or resident care,and organization functions that are essential to providing safe,high quality care.

An operative report documents the details of surgery.The Joint Commission on Accreditation of Health Care Organizations directs that it be dictated immediately after surgery so there is sufficient information in the medical record prior to the patients transfer to the next level of care. The record should include the patients name,date of birth,and hospital or NHS number,the date and time of the operation,names of primary surgeon/physician and assistants,preoperative diagnosis,post operative diagnosis,name of the procedure performed,findings of the procedure,specimens removed,estimated blood loss,complications date and time recorded.

Audit tempelet for completion of Surgery Record.

Report must be completed within 24 hours following the procedure for patient safety and continuity/communication of care purposes.

For the compliance % Score Yes -1 No - 0

Elements	Yes/ No	Remarks
Patients name
Date of birth
Hospital or NHS number
Date and time of operation
Name of primary surgeon /physician
Name of assistant surgeon
Pre operative diagnosis
Post operative diagnosis
Name of the procedure performed
Findings of the procedure
Specimens removed
Estimated blood loss
Complications
Date and time recorded
Total Yes
Total No
% of compli