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Accreditation Audit Essay

A1. Evaluation

Nightingale Community Hospital (NCH) is committed to upholding the core values of safety, accountability, teamwork, and community. In preparation for the upcoming readiness audit, NCH will be launching a corrective action plan in direct response to the recent findings in the tracer patient. Background information on the tracer patient is as follows: 67 year old female postoperative patient recovering from a planned laparoscopic hysterectomy turned open due to complications. Patient developed infection that formed an abscess and was readmitted to the hospital for surgical abscess removal and central line placement for long term IV antibiotics. The tracer methodology was employed when auditors reviewed this patient’s course.

Many things were done well and right with this patient and NCH is pleased to know that the majority of items analyzed with this patient proved that NCH was in compliance with regulatory standards; however, there were some troublesome areas that we need to focus on. The primary focus area that we will put our energies into will be the fact that there was not a history and physical completed on the patient within 24 hours of admission, and in fact it was greater than 72 hours before one was completed.

The Joint Commission mandates standards that are to be met in order to maintain compliance. Standard PC.01.02.03 states that history and physicals must be documented and placed in the patient’s medical record within 24 hours of admission and prior to procedures involving conscious sedation or anesthesia. History and physicals are also considered in compliance if documented 30 days prior to procedures as long as there are no changes documented or the changes in status are specifically noted. (Joint Commission Update, n.d.) A2. Plan

Often, rules and regulations are met with disdain and it is usually because there is no explanation provided as to why the rule exists. The rules for History and physical documentation are in place for a reason and are not just to make things more complicated. History and physicals provide all health care providers that participate in a patient’s care a glimpse into that patient’s health status and immediate concerns. (Shuer, 2002) The information provided in a history and physical paints a portrait for all other health care team members to follow and treat accordingly.

Often, emergent situations may arise where other health care specialty providers may not have the time to glean medical background information from patients and/or their representatives and the history and physical then serves as the go to source of information. Compliance regulations can be hard to understand the reasoning behind them sometimes, but if we all work together to make sure that we meet them, then NCH will continue to embrace the core values that we have worked so hard to instill and embrace. The following outline is a corrective action plan that will ensure compliance with the Joint Commission and bring us up to par for the readiness audit.


Accountable Parties
History and Physical

Physicians & physician assistants

1. Within 24 hours of admission.
2. Within 30 days prior to a procedure involving conscious sedation or anesthesia. Chart reviews and if requirements are not met, patients will be held in the surgical admitting unit and procedures will be delayed. There must be 100% compliance.

B. Sources
Joint Commission Update Study Guide. (n.d.). Retrieved August 31, 2014, from
med2.uc.edu/libraries/GME_Forms/Joint_Commision_Upd_1.sflb.ashx Shuer, L. M. (2002). Improvement needed on h&p documentation. Medical Staff Update, 26(5), Retrieved from med.stanford.edu/shs/update/archives/May2002/chief.html

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