Patient Tracer Discussion for Nightingale Community Hospital

Introduction

The discussion concerns a 67-year-old patient introduced for a state of laparoscopic hysterectomy five weeks before the time when the assessment is done. She was draining plentifully in the wake of admission at the hospital. This was a readmission following a surgery that was done previously and the patient did not heal well. She was suffering from prospective postoperative septicity. Hence, the case required ensuing surgical drainage of an intra-stomach irritation.

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Discussion of an Outstanding Patient Care Issue Based On the Hospital's Surgical Patient Tracer Worksheet

In looking into the hospital's Surgical Patient Tracer Worksheet (SPTW), it has become apparent that the primary area of focus concerning evaluation and care and services should be attended to instantly; especially the nursing design of care record keeping. There are several instances as seen on the worksheet indicating that the record keeping and documentation was not done appropriately since some record files and documents could not be located. One cannot verify whether the documents could be missing because they were not written, or they were written but not procedurally kept. From the statement on the worksheet where the nurse affirms that functional assessment was done without keeping records. As from when the surgery ended, no documentation was kept thereafter. The absence of follow up records, particularly follow up records may put the patient in danger concerning lack of provision of appropriate care from the nursing staff. All through the worksheet, negligence of procedure is evident. the heath care facility is supposed to take part in evaluating every now and then, the patient's condition regarding the characterized time spans and the entire healing process (Buchbinder, Shanks & Buchbinder, 2014). This obliges execution component 6 which requires that a qualified nurse should finish the procedural assessment within one day counted from the time when the patient was admitted (Buchbinder, Shanks & Buchbinder, 2014).

JCAHO standard expresses that hospitals must give concern, cure, as well as administrations as requested and shall be as per the legal directions (Buchbinder, Shanks & Buchbinder, 2014). The hospital is not sonsistent with the performance requirements as per JAHCO regulations. The 7th performance element was breached and the person concerned for the case is the director of nursing who should be able to answer to the negligence. (Buchbinder, Shanks & Buchbinder, 2014). The director should ensure that all services rendered by the facility must be done in accordance to the latest requests by the patients. Before giving patient care, treatment and administrations, the hospital's staff engaged with persistent attention must ensure data is archived and refreshed on the SPTW. The patient service provision designs shall be assessed and refreshed day by day. The medical practitioners in charge of giving medical care are instructed by the nursing Director to appropriately report and refresh the arrangement of responsibility and tracking data on the SPTW. Routine observation is directed and recorded likewise by the attendants on duty (Buchbinder, Shanks & Buchbinder, 2014).

Sooner rather than later, with a review by the Joint Commission of Nightingale Community Hospital is nearly carrying out a study on tracer quietly to gauge their personality, consistency and plan to rescue the dying giant. They shall carry out training which includes a review that guides the procedure of patient care from the reporting time to the time when the patient is released. They will also need to streamline their follow up processes so that to avoid similar mistakes as to in this worksheet, in future. A framework shall be developed that allows the hospital to evaluate and reassess the qualities and shortcomings as to the approach set up (Stahl, 2004).

Corrective Action Plan

The protection documentation and protection of patient information should be a priority for Nightingale Community Hospital, and some remedial measures steps can be taken to reduce the potential for negligence at work. A five-step method for reduction of this issue includes the establishment of recordkeeping policies along with training, conducting a risk assessment, implementing measures for documentation, developing risk mitigation and incident response plan, and making the security of patient information a priority during budget planning (Buchbinder, Shanks & Buchbinder, 2014). The establishment of record keeping policies and training should be completed to ensure that all employees, even those not employed in direct patient care, are educated on the 1996 health insurance regulation (HIPAA) on what comprises to a violation of this regulation (Carter, (2017).

This risk assessment should be conducted for potential breaches to include electronic, paper, and verbal record keeping methods and their ease of access when needed. Any potential violations should be immediately addressed with hospital administration and the area where a breach is possible. Possible breaches will be remedied based on their nature such as tracking the medical practitioner involved in that particular documentation case and him/her answerable for the negligence (Carter, (2017). Electronic breach potential should be conducted by the information systems department, as their expertise in possible areas of electronic breach will be of more benefit to the assessment. Verbal breaches will be addressed during the education of employees.

The establishment of a risk mitigation/incident response plan will enable the hospital to respond promptly to cases of negligence to reduce the potential for a non-record keeping culture as well as provide written instruction for the containment of the breach of in-house procedure, and government reporting criteria (Stahl, 2004). The establishment of the response plan, review of current policies, and establishing an educational process for employees will require additional resources that may not be an existing part of the organization's budget. Revisions to the budget with funds being taken from less vital areas and reallocated to this process should be undertaken as quickly as possible. Future budgets should include designated resources for the continued development, monitoring, and education on the risk of negligence of documentation and secure patient records.

Conclusion

The risk of unintentional negligence of documentation of information on patients is high especially when team leaders are not doing their work as expected. Understanding the regulations of HIPAA and what an organization can do to reduce the potential risk of breaches is essential for avoiding costly penalties. Ensuring that all employees, regardless of the department in which they work, are educated about HIPAA, what constitutes a violation, and the organization's stance on such cases is a significant step in preventing similar situations. While this action plan recommends the risk assessment process be conducted semi-annually, the final decision should rest with the hospital's Risk Management and administration based on knowledge of potential threats.

References

Buchbinder, S. B., Shanks, N. H., & Buchbinder, D. (2014). Cases in healthcare management. Sudbury, Mass: Jones & Bartlett Learning.

Carter, P. I. (2017). HIPAA compliance handbook.

Stahl, M. J. (2004). Encyclopedia of healthcare management. Thousand Oaks, Calif: Sage Publications.