A. Assign the appropriate quality code using the key provided in figure 17.6 (more than one code is possible).

B. Which code is the most common?

C. Which service seems to be a problem?

D. What do you suggest to fix the problem?

documentation. The facility is due for another survey very soon. To ensure that the hospital is in During the last accreditation survey, a hospital had findings related to quality and timeliness of audit should carefully assess documentation compliance for history and physicals (H&Ps) and operative compliance with the Joint Commission documentation standards, you need to conduct a quality audit. This reports (Ops). A history and physical report must be available in the patient's health record before any sur- gical procedure can begin. The H&P can be completed up to 30 days prior to the procedure as long as the within 24 hours of the procedure to be compliant. You have assigned one of your staff to collect data from surgeon updates any information prior to starting the procedure. The Op must be dictated by the surgeo quality and timeliness of documentation. The data collected are presented in figure 17.6. 282 Chapter Figure 17.6. Data for timeliness of documentation study PATIENT DISCHARGE SERVICE QUALITY Admit Date & CODE Procedure Start Time DATE Proce End Time CD 12/23/2018, 16:20 127232087 UOL 12/04/2018 09:15 timed on 12/10/2018 at 1210/2018, 08:44 2702000 12/19/2018, 13.02 12/01/2018, 0751 2070205 12/26/2018121 226 2018 12/27203 215/208.53 4 = No Operative report within 24 hours after surgery Physician Action Time 12/23/2018; no time noted on HAP 12:30 update stamp 12/04/2018, HSP dated June 2018 EN 0704 12/10/2018; HEP signed, dated & EN 06:47 05:05 EN 12/19/2018 Op report dictated EN GS 7 12/26/18 GS 8 12/26/13 GS 12/30/78 GS 10 12/23/18 NE 11 12/2018 NE NE 3 02/16/18 NE OB OR OR OR 12/04/2018 12:09 OR 12/03/2018 23:46 12/16/2018 1055 timed 12/5, 0900 post analysis 1 =HAP >30 days 2-No HSP prior to surgery 3- No update to HSP prior to surgery 12/27/18 01039 12/22 12/07/2018: no date/time on H&P 06:14 12/26/2018 H&P dated 1/24/2018 12/26/2018 Op report not dictated 12/26/2018 H&P dated 11212018 12/2v2018 Op report dictated OV 09/19 12/15/2018 H&P dictated 12/15 2018, 11:46 08:26 12/18/2018 12/18/2018; HSP dictated 12/18/2018, 07:25 78 2006 05:26 1103/2018 12/1/2018 H&P dictated post-op 1271/2018, 07:22 201 12/16/2018, H&P dictated 12/76: 12/6/2015:07:51 1520800 04:56 05:59 12/24/2018; Op report dictated 12/25/2018, 15:00 0.25.2018 22:15 12/29/2018 12/29/2018Op report dictated 12/29/2018, 13:51 02:14 12/29/2018,1500 12/04/2018; Op report dictated 12/04/2018 05:25. 004200 0430 12/23/2018 12/17/2018: H&P dictated 12/15 12/17/2018:1247 09:52 12/15/2018: Limited HSP completed 12/15/201807) 05:14 12/15 07:30 12/04/2018: Limited HSP signed 10:10 dated/timed as 1100 after analysis 12/03/2018: No HSP dictated 17.00 12/15/2018, Op report dictated 06:45 12/05/2018 HEP update dated 07.00 20470 12/2970140 12/7/18 12/18/18 2/72018.140 19 12/2/18 OR 020 650 20 12/06/18 21 12/5/18 0042018 0122 OR 22 12/05/18 12/15/2018, 08:54 15.2010 UR 12/05 2018.06.14 205.2016 09:59 Key