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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.

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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

  1. Using Microsoft Excel, input the data from the Delinquent Record Report. Include report, column and row titles, and the monthly data.
  2. Use Excel to calculate and automatically insert the total number of discharges for the month.
    1. Total discharges = total inpatient discharges + total ambulatory surgeries.
    2. Total operations = total ambulatory surgeries + total inpatient operations.
  3. 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

  1. Using Microsoft Excel, construct both line graphs and bar graphs showing the following:
    1. 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)
    2. 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).
    3. 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

  1. In a Word document, provide a narrative analysis of the findings for the CEO.
    1. Reference the table and use the graphs you prefer to illustrate compliance in the report.
    2. 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.
    3. Was the hospital in compliance for the whole year?

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