Class: Regulations and Compliance

Topic: Comparing Accreditation Standards

Part I Comparing Accreditation Standards Across Health Care Settings

Standards that address appropriate documentation of patient care and effective management of health information can be found among accrediting bodies at each level of health care. While the standards cover the same area, their scope and requirements for compliance can vary widely.

Review the standards for authentication (signing) and timeliness of medical record entries for acute care hospitals, ambulatory facilities, long-term care facilities and mental health hospitals. Create a table to compare and contrast the standards, select which accrediting body’s standard you would recommend if only one standard could be applied to all health care delivery systems and support the reason for your selection. where you describe the corresponding standard for each type of facility. Address these at a minimum the “criteria” below in your table:

1.      Are there requirements that are the same for each standard?

2.      Which clinical staffs are allowed to make entries in the medical record in each type of facility? (e.g. physician, nurse, physician assistant)

3.      Which accreditation standards address the use of electronic signatures?

4.      Explain how the standards differ in terms of type of the entries that should be authenticated (i.e. consultations, procedure notes, progress notes).

5.      How is compliance with each standard to be evaluated (e.g. medical record audit, summary reports)?

Part II Transitioning from Conditions of Participation to Joint Commission Standards

A healthcare facility is interested in pursuing Joint Commission accreditation. Senior management has asked departments to submit reports about implementation of applicable Joint Commission standards in their areas of responsibility. You are the HIM director who will draft a report for implementation of procedures to comply with standards related to Information Management (IM) and Record of Care, Treatment and Services (RC). Using the terms below do an internet search to locate the standards and Condition of Participation needed. Create a document, spreadsheet or table that compares the COP and Joint Commission standards, and address differences in preparation (e.g. accreditation cycles, resources needed) and training and preparing of staff. The report should also include how compliance is reported to and monitored by the Joint Commission.

Joint Commission Standard IM

Joint Commission Standard RC

Conditions of Participation 42 CFR 482.24 Medical Record Services

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