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Attention Wendy Lewis

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.

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