HIIT 101 Moffitt Module 4 Case Study Lab;C.S. 1.1 Ambulatory surgery data collection

1 This study resource was HIIT 101 Moffitt Module 4 Case Study Lab;C.S. 1.1 Ambulatory surgery data collection C.S. 1.1 Ambulatory surgery data collection Northwest Ambulatory Surgery Center provides urology, endoscopy, orthopedic, otolaryngology, and ophthalmology procedures. Physicians for each service are listed below. The Center has a documentation requirement that every patient’s health record must have an H&P prior to surgery. A data collection is being done to verify compliance with that requirement. 1.Determine which data elements should be included in the data collection. • Patient Identification, health perception, self-perception, procedure/date/type of surgery, principals diagnosis, lab results, general and systematic examination, nutritional/metabolic pattern, elimination pattern, exercise pattern, cognitive pattern, sleep/rest pattern, value and beliefs, and coping stress tolerance • 2.Create a data collection checklist to be used in the chart review. Criteria: Notes: Anesthetic risk/evaluation: Admission/pre-surg Assessment: Patient ID.: Health Perception: Self-perception: Procedure/Date/Surgery type: Diagnosis: Departmental consultation Nutritional/Metabolic pattern: Elimination pattern: Activity: Mental status: Beliefs: Tolerance level: 2 surgeries endoscopies Otolary. P urology p. Ortho Opht. P Patient Name:Case #: Age: Weight: Height: Allergies: In June, Northwest Ambulatory Surgery Center conducted a chart audit to determine compliance with the H&P on the chart prior to surgery requirement. The results are as follows: A total of 1220 surgeries were performed in May: 640 endoscopies 160 urological procedures 240 ophthalmologic procedures 120 otolaryngology procedures 60 orthopedic procedures 100 total charts were reviewed: Dr. Northrop 7 charts 6 with H&P 1 w/o H&P Dr. Easton 22 22 with H&P Dr. Westerly 33 30 with H&P 3 w/o H&P Dr. Southcliffe 28 20 with H&P 8 w/o H&P Dr. Penn 10 10 with H&P 1. What deductions can be made about the data collection itself? Out of 1220 surgeries, Dr. Southcliffe performed the most procedure. 2. Propose a more meaningful data collection 3. What deductions can be made regarding the results of the data collection? Out of 100 charts viewed total, only 12 charts were without H&P. 4. Based only on the data collection above, create a graphic design which illustrates the missing H&Ps by service. 3 C.S. Emergency Department Documentation The Emergency Department Chair has asked for an audit of ED records in preparation for an upcoming Joint Commission survey. Your staf conducted the audit against the Joint Commission standard that addresses ED documentation. The results were very poor, with no consistency in documenting the required components. You check the medical staf by-laws and realize that there are no specifics related to ED documentation. 1. Determine the Joint Commission documentation requirements for Emergency Department reports. List them here. Patient demographic info., arrival time, means of arrival, name of person bringing patient to ED, pertinent history of illness, physical findings, diagnosis test, treatment, disposition of patient, patient status before discharge, and patient signature. 2. Audit the five representative ED cases below to determine the major areas in need of documentation improvement. As HIM director, present your results in a short memo to the ED Department Chair, Dr. Wilkerson. time of arrival of the patient is not mentioned. Discharge report and follow up of physician is not mentioned. Document of Discharge treatment advice must be improved. Condition at discharge must be documented properly. The name of the person that dropped patient off at the hospital isn’t listed Chart Title 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Northrop Easton Westerly Southcliffe Penn H&P w/o H&P