Nightingale Community Hospital

Executive Summary

Nightingale Community Hospital is a not-for-profit hospital that provides many services such as general medical services and surgical services, critical care and emergency services and cardiology and imaging services. The staff of this hospital values themselves on safety, the community, teamwork and accountability. Because this is a not-for-profit hospital, this allows them to provide cost effective services to its patients and clients. Medical staff within this hospital strives to ensure that all patients see their passion of providing excellent healthcare from the time the patient checks in to the hospital until they are discharged.

Currently, Nightingale Community Hospital is preparing for an accreditation audit to be performed by the Joint Commission on Accreditation of Healthcare Organizations. In preparation for this audit, there are many variables and priority focus areas that must be considered in order to ensure compliance with Joint Commission standards. Priority focus areas include infection control, information management, medical management and communication. For this summary, the priority focus area that will be examined in this summary is information management. Information management is a very important key factor within any healthcare organizations because this includes patient information regarding their health status and other notes that doctors have made pertaining to the patients care. Because this information is confidential, it is important to have the proper systems in place to ensure that this private information is protected and is only viewable by the appointed medical staff. Information management also plays a huge role in overall patient care.

The audit that will take place for Nightingale Community Hospital will focus on three Joint Commission Standards, in which the first one is IM.02.02.01 which addresses how effective the hospital manages the collection of health information. This standard examines three elements of performance, or EPs which includes the usage of uniform data sets to standardize data collection in the hospital, the usage of standardized terminology, definitions, dose designations and whether the hospital follows a list of prohibited abbreviations, symbols and dose designations. (The Joint Commission, 2013)

While examining the first EP and the documentation that is used by Nightingale Community Hospital, one form that is used is the Admission Order. This is a standard form that is used to document patient information, such as vital signs, diet, reason for hospital visit, medications and lab tests. This form is filled out for every patient of this hospital. This form is also used to keep track of patient’s history and what tests were performed previously. The Admission orders is of great importance and should be kept in a place where only those that may need it, can have access to it, such as the patients physician. These forms should also undergo review to ensure that it is filled out correctly and contains all the needed information. One key item to note is that there are pre checked boxes on this form that should be removed. Because each patient is different, it is very important to use blank forms and filled out in accordance to the actual patient that the form is pertaining too. This form also adheres to the second EP, which requires the hospital to use standardize terminology, definitions, abbreviations, acronyms, symbols and dose designations. (The Joint Commission, 2013)