Both regulatory compliance and top-notch healthcare delivery quality rely on the triad of patient healthcare data, which is complete and accurately planned. Primary healthcare workers perform data-gathering responsibilities, which enable patients to make decisions accordingly. As this review delves profoundly into Pam Ray’s medical records, we uphold the thoroughness of the Joint Commission’s standards. First, we delve into important aspects, including family history, recording the procedure’s particulars, who the attending surgeon is, the anesthetic used, and the medications used. By performing this, we can check whether Pam Ray’s medical report matches the Joint Commission requirements. Finally, our project aims to bring about better patient safety, improved quality of care, and all aspects of compliance with regulations for healthcare establishments.
Pam Ray’s health record allows us to scrutinize her health history, provides data on her care, and contains information about her treatment. Thrombocytopenic purpura, congestive heart failure, cirrhosis, and arteriosclerotic heart disease, similar to those in her family, are all conditions running in her lineage. Dr. Dunn got six teeth out of it and did a bone surgery called an alveolectomy on the jaw. Nor could one tell from the accessible records whether any anesthesia had been applied to the malady (Schmaltz et al., 2023). However, dental surgery was likely done under general anesthesia, as this is how procedures are normally discharged; Pam Ray will be taking Losartan and digoxin to ease congestive heart failure.
All patients’ records are checked normally to comply with the rules detailed in the Record of Care (RC). Among the examples are the patients’ identity, exact documentation, the doctors’ signatures on every piece of information, registration forms for consent being well-comprehended, and even the summary upon discharge (Schmaltz et al., 2023).
Research has been successful in identifying several gaps in Pam’s medical history. The following errors have been identified: the patient’s name discrepancy; the discharge summary’s lack of completeness; the absence of instructions on the patient’s return to normal activities, diet, and progress; the missing date of birth in several pages; the lack of the patient’s insurance or billing information in the face sheet; and one place that the physician’s name is missing (Alalade et al., 2020). Another case of disagreement concerns the marking down of anesthetic types and the signing of consent documents.
As demonstrated by these shortcomings, Pam Ray’s healthcare record violated certain TJC criteria, which needed to be revised. The set standards are to achieve the same objectives, including accurate patient identification, an exhaustive transfer plan, and proper documentation. Being unable to identify patients, get signed by doctors, and have discharge summaries with detailed information can have adverse effects on patient safety, errors in diagnosis, and two levels of continuity in treatment (Alalade et al., 2020). Other than the fact that TJC noncompliance can also reflect negatively on the performance of the hospital’s quality assurance standard, noncompliance may also attract regulatory fines or accreditation issues.
Several documentation and performance standards issues could have been more annoying while reviewing Ms. Pam Ray’s medical files. These challenges define the time and effort we need to invest in problem-fixing to ensure the high quality of the services we provide, compliance with the regulations, and protection of patients. Meeting quality standards and obtaining ideal outcomes for patients calls for using systems that can be relied upon regarding the accuracy and completeness of patient health information. The priorities should reflect this by doing regular audits for compliance, training of employees, and strict compliance with the regulatory standards. Robust documentation systems should support these efforts. Resolving these issues will give healthcare organizations a chance to increase patient happiness and trust, and the quality of care provided.
Alalade, M. A., Jinsiwale, D. N., & Arungunasekaran, A. (2020). Improving the quality of clinical records: audit and literature review. Journal of Gynaecology and Paediatric Care, 2(2).
Schmaltz, S. P., Longo, B. A., & Williams, S. C. (2023). Consistency of Home Health Performance Associated with Joint Commission Accreditation Status. Home Health Care Management & Practice, 10848223231213067.