Accreditation Audit Essay Example for Free

Accreditation Audit endeavorA1. EvaluationNightingale Community Hospital (NCH) is committed to upholding the core values of safety, accountability, teamwork, and community. In preparation for the future readiness audit, NCH will be launching a nonindulgent action plan in compute response to the recent findings in the tracer longanimous. Background information on the tracer patient is as follows 67 year old female postoperative patient recovering from a planned laparoscopic hysterectomy dour open due to complications. Patient developed infection that formed an abscess and was readmitted to the hospital for surgical abscess removal and rally line placement for long term IV antibiotics. The tracer methodology was employed when auditors reviewed this patients course.Many things were done well and right with this patient and NCH is pleased to know that the majority of items analyzed with this patient proved that NCH was in compliance with regulatory standards however, at that place were some troublesome areas that we need to focus on. The primitive focus area that we will put our energies into will be the fact that there was not a tale and physical completed on the patient within 24 hours of admission, and in fact it was greater than 72 hours before one was completed.See more My Writing Process EssayThe Joint commissioning mandates standards that are to be met in order to maintain compliance. Standard PC.01.02.03 states that history and physicals must be authenticated and placed in the patients medical record within 24 hours of admission and prior(prenominal) to procedures involving conscious sedation or anesthesia. History and physicals are also considered in compliance if documented 30 days prior to procedures as long as there are no changes documented or the changes in status are specifically noted. (Joint Commission Update, n.d.) A2. PlanOften, rules and regulations are met with disdain and it is usually because there is no explanation declare oneselfd as to why the rule exists. The rules for History and physical documentation are in place for a reason and are not just to make things more complicated. History and physicals provideall health care providers that participate in a patients care a glimpse into that patients health status and immediate concerns. (Shuer, 2002) The information provided in a history and physical paints a portrait for all other health care team members to follow and address accordingly.Often, emergent situations may arise where other health care specialty providers may not swallow the time to glean medical background information from patients and/or their representatives and the history and physical then serves as the go to source of information. Compliance regulations can be hard to understand the reasoning behind them sometimes, barely if we all work together to make sure that we meet them, then NCH will continue to force the core values that we have worked so hard to instill and embrace. Th e following outline is a corrective action plan that will ensure compliance with the Joint Commission and bring us up to par for the readiness audit.ActionAccountable PartiesTimeframeMeasurementHistory and PhysicalPhysicians physician assistants1. Within 24 hours of admission.2. Within 30 days prior to a procedure involving conscious sedation or anesthesia. chart reviews and if requirements are not met, patients will be held in the surgical admitting unit and procedures will be delayed. thither must be 100% compliance.B. SourcesJoint Commission Update Study Guide. (n.d.). Retrieved August 31, 2014, frommed2.uc.edu/libraries/GME_Forms/Joint_Commision_Upd_1.sflb.ashx Shuer, L. M. (2002). Improvement require on hp documentation. Medical Staff Update, 26(5), Retrieved from med.stanford.edu/shs/update/archives/May2002/chief.html