Health Records

Oachs and Watters (2020) state that a Health Record is a comprehensive collection containing handwritten notes, transcribed reports, electronic data, and digital visuals showcasing the input and knowledge of numerous healthcare providers (p.100). These records provide concrete evidence of the treatment performed for the patient. It is imperative that, providing high-quality care and to maintain a secure and protective healthcare standard, health providers ensure that any individual patient’s health record is fought for its accuracy and maintained. All of this takes place while upkeeping legal regulations of the state-specific and federally constitutional accreditation standards.
During the record review, it was found that Pam Ray was hospitalized for advanced periodontitis and infected teeth. While her medical history does not show any prior diagnoses of diabetes, heart disease, or tuberculosis, she did undergo an alveolectomy and had six teeth extracted from her mandible during her procedure with Dr. Jon Black. The medication records show that the patient was to be administered Tylenol with Codeine as needed for pain management, specifically 1/2 grain taken by mouth four times a day.
The Joint Commission Standards (TJC) aims to assist Health Care Organizations in measuring and improving performance. The Joint Commission sets standards that facilities must follow to receive and maintain accreditation. The standards focus on improving the quality and safety of patient care. To be accredited, all standards throughout an entire healthcare organization must be met. Specifically regarding records of care, treatment, and services that are routinely reviewed by The Joint Commission for compliance with RC standards include: complete and accurate medical records, authenticated entries, timely entries, record audits, retaining records, transmitting and receiving data, medical record reflects- patient care, treatment and services (patient name, the date the patient was born, sex of the patient, address of the patient, legal status of the patient, patient’s legal guardian’s name (if the patient is a minor), high risk procedures and anesthesia or sedation, orders are verbally received and recorded by qualified staff, discharge information (The Joint Commission E-dition, 2020). This data speaks to record content, privacy, information security, ethical behavior, patient rights training, and confidentiality follow laws, regulations, and standards.
Upon reviewing Pam Ray Medical Record, I noted a considerable amount of missing information, incorrect information and things that just didn’t make sense. The first thing that I came across is missing on every page the date of birth has the year missing, as does the Face Sheet. (This violates TJC standards regarding demographic information.) The year of admission and discharge is also missing on the Face Sheet and every other page that it is listed. The “relationship to patient” for the guarantor is not listed. There is no insurance and billing information listed. And no attending physician authentication. Pam Ray’s Consent to Admission form has not been signed by Pam Ray; Pam Ray has not signed Consent to Release Information for Reimbursement; Patients name entered incorrectly as Jones, Sara on Advance Directive and patients initials are missing; Physician did not sign the Discharge summary; Admitting diagnosis is missing on History and Physical Exam; Physician did not sign under Discharge Plan on Progress Notes; The time out is wrong on second page of Laboratory Data; Dates are illegible on Consent for Operation; No time is on Pathology Report; and there are several dates and times missing in the nursing notes. Discharge Summary is not signed and all element not there.
Global Care Medical Center had several shortcomings. Although the consent form was present in the patient’s file, it did not bear the patient’s signature. According to the criterion of TJC standard RC.02.01.01, an adequately performed informed consent form should have proof of the patient’s compliance, agreement, and comprehension of the care, treatment, and services offered—shown by a signed written statement or an electronic mark. (E-dition, The Joint Commission, 2020.) Moreover, the discharge summary lacked a completed physician signature. TJC standard RC.01.02.01 states that the author of an entry in the medical record must authenticate it. (E-dition, The Joint Commission, 2020.) The patient’s name was completely inaccurate on the consent to admission form. According to TJC standard RC.02.01.01, the medical record must be outfitted with precise demographic information (The Joint Commission E-dition,2020). The lack of insurance/billing details is also noticeable. TJC standard RC.01.01.01 obliges the hospital to keep comprehensive and accurate medical records for every single patient (The Joint Commission E-dition, 2020). All these mishaps can be grouped together cause when one piece is wrong or not there at all, the record is no longer accurate. If any one thing is not right, the healthcare organization could fail to meet the accreditation standards of the Joint Commission or face fines.
To sum up, the Global Care Medical Center has some room for improvement in its treatment of patients. Pam Ray had several discrepancies in her records discovered by the speaking agent. These can largely be categorized into two main areas: authentication issues and missing important information. Its reckless neglect and poor handling of health records are critical in the field of health care. Any discrepancy, no matter how trivial it may be, can ultimately lead to drastic consequences and costly mistakes in the long run. It is remarkable that Global Care Medical Center not only failed to deal with a series of insalubrious health records, but also showed no interest in correcting and updating these records. This is a wake-up call for the Global Care Medical Center to maintain and follow the principle of health records, and also to adhere and respect the principle for maintaining the health records and medical histories of patients in accordance to Health Insurance Portability and Accountability Act (HIPAA).