Scenario

For the purpose of this assignment, assume that you are the manager of the HIM Department of General Hospital. The hospital is due for a Joint Commission accreditation survey in six months. The CEO has asked for a report regarding medical staff compliance with Joint Commission requirements for delinquent records last year.

Information Regarding Joint Commission Standards

The following are Joint Commission standards that address timeliness of medical record completion.

Information Regarding General Hospital’s Policies, Procedures, Rules, and Regulations

To implement this standard, General Hospital’s policies and procedures state:

- The medical record delinquency rates are monitored on a monthly basis;
- Action will be taken when a problem is indicated; and
- Data will be available to demonstrate improvement.

In addition, to ensure the timely entry of all significant clinical information into the patient’s record, the Medical Staff Rules and Regulations list the following documentation requirements:

- The total number of delinquent records may not exceed 50% of the total number of inpatient discharges and ambulatory surgeries performed for the month.
- The total number of delinquent history and physicals may not exceed 2% of the total number of inpatient discharges and ambulatory surgeries performed for the month.
- The total number of delinquent operative reports may not exceed 2% of the total number of inpatient operations and ambulatory surgeries.

Assignment Instructions

Download this Delinquent Record Report and use the data it contains to complete the following:

Part-1: Create Delinquent Record Report Table

- Using Microsoft Excel, input the data from the Delinquent Record Report. Include report, column and row titles, and the monthly data.
- Use Excel to calculate and automatically insert the total number of discharges for the month.
- Total discharges = total inpatient discharges + total ambulatory surgeries.
- Total operations = total ambulatory surgeries + total inpatient operations.

- Use Excel to calculate and insert the number of delinquent records, history and physical exam reports (H & Ps), and operative reports permitted according the Medical Staff Bylaws for each month in 20XX based on the hospital’s statistics for that month. To calculate the year’s figure, the monthly average should be used.
**Therefore, have a final monthly average column and use Excel to compute the averages for all rows**.

Part-2: Create Line and Bar Graphs

- Using Microsoft Excel, construct both line graphs and bar graphs showing the following:
- The hospital’s actual delinquent records compared to the total number of delinquent records permitted by the Medical Staff Rules and Regulations for the 12 months in 20XX (do not include the total for the year)
- The hospital’s actual delinquent H & Ps compared to the total number of delinquent H & Ps permitted by the Medical Staff Rules and Regulations for the 12 months in 20XX (do not include the total for the year).
- The hospital’s actual delinquent ORs compared to the total number of delinquent ORs permitted by the Medical Staff Rules and Regulations for the 12 months in 20XX (do not include the total for the year).

Part-3: Write Narrative Analysis

- In a Word document, provide a narrative analysis of the findings for the CEO.
- Reference the table and use the graphs you prefer to illustrate compliance in the report.
- Include in the analysis whether the hospital was in compliance with the Medical Staff Rules and Regulations in each of the three areas during each month of the year.
- Was the hospital in compliance for the whole year?
- Be sure your analysis is free of spelling and grammar errors.

Submit the following to your instructor:

- Delinquent Record Report Table
- Line and bar graphs
- Narrative analysis of findings

**Expert Solution Preview**

Introduction: This assignment requires the students to assume the role of the manager of the HIM Department of General Hospital and create a delinquent record report table using Microsoft Excel. The students also need to construct line and bar graphs using Excel and provide a narrative analysis of the findings for the hospital’s CEO.

Part-1: To create the delinquent record report table, the students should input the data from the Delinquent Record Report into Excel and include report, column and row titles, and the monthly data. They should also use Excel to calculate and insert the total number of discharges and operations for the month. Furthermore, they need to calculate and insert the number of delinquent records, history and physical exam reports, and operative reports permitted according to the Medical Staff Bylaws for each month in 20XX based on the hospital’s statistics for that month. To calculate the year’s figure, the monthly average should be used, and a final monthly average column should be added. The students should use Excel to compute the averages for all rows.

Part-2: To create the line and bar graphs, the students should use Excel to construct the graphs showing the hospital’s actual delinquent records, H & Ps, and ORs compared to the total number of delinquent records permitted by the Medical Staff Rules and Regulations for the 12 months in 20XX (do not include the total for the year).

Part-3: In the narrative analysis, the students should provide an analysis of the findings for the CEO. They should reference the table and use the graphs they prefer to illustrate compliance in the report. The analysis should include whether the hospital was in compliance with the Medical Staff Rules and Regulations in each of the three areas during each month of the year. Additionally, the students should mention whether the hospital was in compliance for the whole year. It is essential to ensure that the analysis is free of spelling and grammar errors.