No problems were found in 3Q2017 related to release of information from the Health Information Department and training of new employees/contract staff; however, compliance with current law and HIPAA regulations needs to be strictly adhered to requiring training, education, and policy development at all levels. Actions: The above indicators will continue to be monitored. Regulatory and Compliance Standards in Documentation Ensuring Fiscal Responsibility in Documentation and Billing Practices Indicator and Rationale for Selection 1Q2017 2Q2017 3Q2017 4Q2017 Identification Data 98% 100% 98% 54/55 61/61 66/67 Medical History, including complaint; HPI; past, social 93% 100% 100% & family hx.; ROS, and physical exam w/in 24 hr. 55/55 61/61 67/67 conclusion and plan 4 7 11 Refused Refused Refused Summary of patient’s psychosocial as appropriate to the 71% 82% 81% patients * 39/55 50/61 54/67 16 > 7 11 > 7 13 > 7 days days days Psychiatric Evaluation in patient’s record w/in 24 hrs. of 95% 93% admission 52/55 100% 62/67 1 > 24 61/61 5 > 60 2 > 60 Physician (TO/VO w/in 72 hr.) 96% 98% 94% 151/157 127/130 128/135 Evidence of appropriate informed consent 100% 100% 100% 55/55 61/61 67/67 Clinical observations including the results of therapy. 100% 100% 100% 55/55 61/61 67/67 Nursing discharge Progress Note with time of discharge 95% 87% 84% departure 52/55 53/61 56/67 Consultation reports, when applicable 80% 100% 75% 99/123 61/61 190/253 Results of autopsy, when performed N/A N/A N/A Advance Directive Status on admission and SW follow up after 93% 87% 93% 51/55 53/61 62/67 Notice of Privacy 100% 100% 98% 55/55 61/61 66/67
No problems were found in 3Q2017 related to release of information from the Health Information Department and training of new employees/contract staff; however, compliance with current law and HIPAA regulations needs to be strictly adhered to requiring training, education, and policy development at all levels. Actions: The above indicators will continue to be monitored. Regulatory and Compliance Standards in Documentation Ensuring Fiscal Responsibility in Documentation and Billing Practices Indicator and Rationale for Selection 1Q2017 2Q2017 3Q2017 4Q2017 Identification Data 98% 54/55 100% 61/61 98% 66/67 Medical History, including complaint; HPI; past, social & family hx.; ROS, and physical exam w/in 24 hr. conclusion and plan 93% 55/55 4 Refused 100% 61/61 7 Refused 100% 67/67 11 Refused Summary of patient’s psychosocial as appropriate to the patients * 71% 39/55 16 > 7 days 82% 50/61 11 > 7 days 81% 54/67 13 > 7 days Psychiatric Evaluation in patient’s record w/in 24 hrs. of admission 95% 52/55 1 > 24 2 > 60 100% 61/61 93% 62/67 5 > 60 Physician (TO/VO w/in 72 hr.) 96% 151/157 98% 127/130 94% 128/135 Evidence of appropriate informed consent 100% 55/55 100% 61/61 100% 67/67 Clinical observations including the results of therapy. 100% 55/55 100% 61/61 100% 67/67 Nursing discharge Progress Note with time of discharge departure 95% 52/55 87% 53/61 84% 56/67 Consultation reports, when applicable 80% 99/123 100% 61/61 75% 190/253 Results of autopsy, when performed N/A N/A N/A Advance Directive Status on admission and SW follow up after 93% 51/55 87% 53/61 93% 62/67 Notice of Privacy 100% 55/55 100% 61/61 98% 66/67
2017Q3.docx