Patient Health Record System Report

1PATIENT HEALTH RECORD
Nursing
Name of the Student
Name of the University
Author Note

2PATIENT HEALTH RECORD
Patient Health Record and Review of Record
Name of the patient is Pam Rat, a 63-year old female. She works as a cleaner and is
single. She is White (W) by birth, was appointed to treat advanced periodontal disease, and
infected teeth under the supervision of Dr. Harold Dunn (MD). Her principal diagnosis
indicated that she is suffering from carious mandibular teeth. Her secondary diagnosis
includes thrombocytopenic purpura, congestive heart failure, arteriosclerotic heart disease,
cirrhosis and chronic alcoholism. The doctor has prescribed the extraction of 6 mandibular
teeth through mandibular alveolectomy. The operation will be conducted under general
anesthesia through xylocaine infiltration. Her family history indicates no known cases of
diabetes, heart disease and tuberculosis. The main medications used are Lanoxin (0.125 mg
daily orally), Dalmane (30 my at night orally) Vistaril (50 mg, intramuscular injection),
Robinul and Nubain.
Joint Commission Standards and Expectations
Identify the Data
The data routinely reviewed by TJC for compliance with RC standards include role of
the healthcare organization of retaining the clinical records of its patient (RC: 01.05.01). The
clinical record of Ray though had many flaws, but the organization was successful in
retaining the patient’s record. Second aspect of the TJC compliance is RC.02.01.01. This
signifies that the clinical record contains the required information that reflects the overall
patient's care, treatment, or services that is being offered. The patient progress report contains
the list of medication that was prescribed with dosage, time and route of administration alon g
with detailed pathology report, past medical history.

3PATIENT HEALTH RECORD
Missing Data
The record is not complete. The data was missing under several occasion. Under the
Advance Directive page, the name of the patient is enlisted as Jones Sara. The date of birth of
Ray's is missing on the last page, the insurance information for Ray is also missing, therefore
it will be difficult for Global Care Medical Center to bill her for the treatment that was
administered thus, violating the standard for RC.02.01.01. Standard for RC.01.02.01 was not
also breached as the forms lack physician’s signature, proper discharge summary along with
the face sheet of in-patient (The Joint Commission (TJC), 2014).
Deficient
The main TJC standards where the hospital is deficient as retrieved from the missing
data include standard RC.02.01.01 and RC.01.02.01. RC.01.02.01 mainly gives importance
towards the authenticated documentation of the patients’ record and this must be done by
authorized professionals with a proper signature of the registered professionals at the end.
RC.02.01.01 accurate documentation of the patients past, preset medical history along with
other identification details in order to generate evidence-based practice guidelines. however,
disparity in health equity is indicated (TJC, 2014). Violation to these rights at the legal level
might impose significant legal threats over the registration validity of the health-care
organization as well as the physicals. According to the regulation published by HER, proper
documentation of the patients’ information helps in the generation of the clinical alerts and
proper reminders to the healthcare providers. Since majority of the information about the
health status of Pam Ray is incomplete, it might lead to the generation of fatal health threats
and confusion about the therapy planning among the healthcare service providers. At last, it
can be stated that violation of the RC standards might cause the Global Care Medical Center
to lose its accreditation from TJC (McWay, 2013).
Systems and Technology