Discharge summaries will be completed Out of 63 discharge 79% 100% within 15 days of discharge. summaries, 50 were completed within 15 days of discharge. All forms/revisions to be placed in the Three revised forms, two new 100% 100% medical record will be approved by the forms, and one deleted in Medical Records Committee. 1Q2018 (see minutes). Medical transcription will be timely and 642 dictated reports were 100% 90% accurate. completed within 24 hours. Data Analysis: The indicators are based on the review of sample discharged records. There was a 95% compliance with 30-day record completion. Weekly needing attention” lists are distributed to medical “charts staff, including the Medical Director, along with the Superintendent, Risk Manager and the Quality Improvement Manager. There was 100% compliance with timely & accurate medical transcription services. Actions: Continue to monitor. II. Measure Name: Confidentiality 1Q2018 1Q2018 Findings Compliance Indicators Target All patient information released from 3,242 Requests for information 100% 100% the Health Information Department (192 requests for patient will meet all Joint Commission, State, information and 3,050 police Federal & HIPAA standards. checks) were released. All new employees/contract staff All new employees/contract 100% 100% will attend confidentiality/HIPAA attended confidentiality/HIPAA training. training. Patient confidentiality/privacy issues 0 privacy incident reports. tracked through incident reports. Summary: The indicators are based on the review of all requests for information, orientation for all new employees/contract staff and confidentiality/privacy-related incident reports.
Discharge summaries will be completed within 15 days of discharge. Out of 63 discharge summaries, 50 were completed within 15 days of discharge. 79% 100% All forms/revisions to be placed in the medical record will be approved by the Medical Records Committee. Three revised forms, two new forms, and one deleted in 1Q2018 (see minutes). 100% 100% Medical transcription will be timely and accurate. 642 dictated reports were completed within 24 hours. 100% 90% Data Analysis: The indicators are based on the review of sample discharged records. There was a 95% compliance with 30-day record completion. Weekly “charts needing attention” lists are distributed to medical staff, including the Medical Director, along with the Superintendent, Risk Manager and the Quality Improvement Manager. There was 100% compliance with timely & accurate medical transcription services. Actions: Continue to monitor. II. Measure Name: Confidentiality Indicators 1Q2018 Findings 1Q2018 Compliance Target All patient information released from the Health Information Department will meet all Joint Commission, State, Federal & HIPAA standards. 3,242 Requests for information (192 requests for patient information and 3,050 police checks) were released. 100% 100% All new employees/contract staff will attend confidentiality/HIPAA training. All new employees/contract attended confidentiality/HIPAA training. 100% 100% Patient confidentiality/privacy issues tracked through incident reports. 0 privacy incident reports. Summary: The indicators are based on the review of all requests for information, orientation for all new employees/contract staff and confidentiality/privacy-related incident reports.
RiverviewQuarterlyReport1Q2018.docx