A patient’s health record is a comprehensive summary of the patient’s past and current medical diagnoses, treatments, and procedures. It may also include family history, pre-existing conditions, allergies, and prior surgeries.
The health record can be transferred electronically as a document file or as an image file to other organizations that are authorized to view it.
Accreditation organizations use the health records from some healthcare providers for evaluation purposes. A review of these records can show trends in the quality of care for patients with similar diagnoses or procedures.
Accreditation organizations may also require hospitals to submit patient charts so they may evaluate accreditation processes specific to that hospital for possible improvement opportunities.
Accreditation organizations may also require hospitals to submit patient charts related to surgery cases or episodes of care. These records help accreditation organizations determine how well the hospital performs important surgical and non-surgical processes.
Some accreditation bodies may require hospitals to submit patient charts for specific surgical procedures, such as joint replacements, cardiac surgery, and cancer surgeries.
In these cases, the hospital has selected patients who have had similar procedures performed. The charts document whether the hospital’s methods for preparing patients before surgery effectively reduced surgical site infections for their patients. The charts also show how well the hospital’s surgical team worked together to recover the patient.
Accreditation bodies also require hospitals to submit records for patients who have died of heart attack, stroke, and acute respiratory distress syndrome (ARDS).
The records show how well hospital staff responded to these life-threatening situations. Some accreditation bodies may require hospitals to submit these records quarterly.
Patient charts provide information that enhances accreditation organizations’ ability to evaluate various aspects of the organization’s post-operative quality care.
Some accreditation organizations require the submission of medical records even when the patient is not hospitalized. Accreditation organizations may also require the submission of medical records, such as:
Some accreditation organizations require the submission of a health record to demonstrate how effectively a hospital implements processes that protect patients from infections after surgery or in life-threatening situations, such as heart attack and stroke.
Accreditation bodies review these records to determine if the hospital’s processes are working by reviewing indicators, such as mortality rates and readmission rates.
To Generate A Report To Be Used In Performance Improvement:
A health record review might reveal that a specific “practice” is not being followed (e.g., the proper use of donated blood to screen for infectious diseases). This can then be used in performance improvement activities in part or whole or as a basis for new performance standards.
The accreditor might also use it to determine whether there is any patient harm associated with the deviation from the practice and decide appropriate action.
To Support A Survey:
The health record review may be used to develop new survey questions or add more detail to survey questions developed using other information sources.
To Document Compliance With A Survey:
The health record review might reveal that a patient or family is troubled or dissatisfied by the communication from staff reviewed during the survey.
It may be documented in the survey responses and could prompt the need for additional action to improve the care team’s communication with patients.
A health record review may also be necessary as part of an accreditation body’s investigation into a complaint about healthcare professionals’ improper care or unprofessional conduct.
Accreditation and other quality assessment organizations use patient charts to evaluate process improvement efforts at a hospital, such as reducing surgical site infection rates or improving communication between hospital teams after a surgical procedure.
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