University Nursing Report: Patient Health Record Analysis and Review

This report analyzes a patient health record from Global Care Medical Center, focusing on a 63-year-old patient named Pam Ray, with multiple diagnoses including carious mandibular teeth, thrombocytopenic purpura, congestive heart failure, arteriosclerotic heart disease, cirrhosis, and chronic alcoholism. The analysis examines the record's compliance with The Joint Commission (TJC) standards, identifying deficiencies in documentation, including missing information like the patient's date of birth, insurance details, and physician signatures. It evaluates the current electronic health record (EHR) system, highlighting gaps such as incomplete forms and the lack of mandatory fields. The report recommends improvements to data collection and storage, including upgrading the EHR software, providing training to healthcare professionals, and implementing stricter documentation protocols. Secondary data sources, such as the patient's progress report and pathological reports, are discussed. The report concludes with recommendations for enhancing compliance, including training for nursing professionals and improving electronic medical records to reduce errors, ultimately aiming to improve patient care and ensure adherence to TJC standards.

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

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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.

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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

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Data Collection and Storage
At present, Global Care Medical Center makes use of diverse data entry systems in
order to collect and store patient’s data. Electronic health record (EHRs) is used as the data
entry procedure is used for recording patient clinical information and other vital signs. The
nurses or clinicians enter the information in a health record in the online form as evident
from the printed or digitalized version of the form. Patient’s medical record number is used
as unique identification number. Wang, Khanna and Najafi (2017). stated that use of the
EHRs as a medium of entering patients’ health information data is more error free in
comparison to manual data entry and is also easily accessible by the other healthcare
professionals. The hospital also reflective mode of data collection in which clinicians record
their personal opinion and experience while caring for the patient (experience of Dr. S.
Anderson, DPM addressing the concern of Mr. Ray, a visiting doctor called on by Dr.
Black). The pathological report was enlisted in a printed format as retrieved from the
pathological unit.
Gaps or Issues
The gaps/issues with the current systems/technology include: the EHR software used
for data entry has numerous flaws as it accepts the consent form that do not have doctor’s
signature and date of data entry written is asterisk version. The name of the physician is also
missing in the operation report. The improvement can be done through development of
mandatory filed in the all the forms. Such that proper aggregation of data, followed by date
time and signature of the doctor will be mandate in order to submit the form in the server.
Providing easily digestible visuals that can be understood easily by the nursing professionals
will be helpful in categorical filling of the forms in the EHR service (Kahn et al., 2016). The
automation of the overall manual data entry process like automatic update of the date and

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time will be helpful to increase the overall efficacy of the data entry while reducing the
chances of errors and saving time in the overall process of data entry (Stadler et al., 2016).
Recommendations
The organizations can take license of superior software version of the EHR and that
required specifications for the data entry process. This will be followed by training of the
healthcare professionals under the guidance of the trained IT (information technology)
professionals in order to get accustomed with the process of handling the EHR forms online
and to access it remotely. Proper awareness training must be conducted further in order make
the healthcare professionals to identify the importance of the proper documentation of the
patients’ health information (McWay, 2013).
Secondary Data Sources
Created (1 paragraph)
The secondary data sources are derived from the patients’ progress report based on his
or her current medical history, pathological report and past medical exposure. The
information is mainly objective through the subjective and objective data focusing on the
patients’ health-related information. The secondary data sources mainly comprise of the data
collected for specific rather than registry under consideration (like processing of the
insurance claims and standard medical care). The primary data collected are considered as
secondary data from the perspective of a second registry only when the lining is done
(Gliklich, Dreyer & Leavy, 2014).
The information about the secondary data associated with the case study in order to
generate database was collected from the pathological report, prognosis of the patient, the
previous case history of the patient, the subjective data of the patient along with the remarks
given by the doctors. The collection of the secondary data in this case was mainly used for

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the generation of the national registries in hospital inpatient fact sheet of Global Care Medical
Center.
Data Elements
At present The Joint Commission has only one policy facilitating the approach of the
correct documentation. However, the policy approach is guided towards the proper
enrollment of the medication, MM.01.01.01-The organization plans its medication processes
(The Joint Commission (TJC), 2014). The Joint Commission must come up with further
implementation of the policy planning directed towards strict judiciary proceedings in case
any violation towards the documentation of the patient information. Strict regulation must be
undertaken in the registry process for highlighting the errors.
Recommendations
Data Required
The data elements that are important in order to comply with the TJC’s IM and RC
standards include, proper incorporation of the correct name of the patient in all the pages.
Enlisting the correct date of admission, date of birth and insurance policy number will be
important in order to adhere the TJC’s standard (RC.02.01.01). Proper incorporation of the
missing information like physicians’ signature and signature of the patient in the informed
consent is important for adhering RC.01.02.01 standards.
Organization’s Compliance
The organization is not complaint to the requirements set forth by TJC. RC.01.01.01:
states that it is the duty of the organization to maintain complete and accurate medical record.
However, Global Care Medical Center did not maintained accurate medical records as it
include name of the different patient Jones Sara in the Advance Directive field. Moreover,
Ray's Inpatient Face Sheet, lacks proper information like: The date of birth of Ray is missing
yet Ray's age was documented as 63yrs old. Guarantor name and address are the same as the

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patient's name and address. Ray's insurance and policy number is filled as Not Applicable
(NA).
Registry Compliance (1–2 paragraphs)
RC.02.01.03 states that it is the duty of the organization to maintain patient’s clinical
record din case of operative or other high-risk procedures along with the use of moderate or
deep sedation or anesthesia. The information related to anesthesia is stated in the progress
note. Ray was given general anesthesia. There also consent form related to the order of
anesthesia and the same was signed by the doctor and the patient under the presence of the
witness. However, there was no documentation of the restrain (RC.02.01.05).
Recommendations (Appx. 2 paragraphs)
My first recommendation in order to increase the level of compliance of the
deficiencies is giving proper training to the nursing professionals in order to increase their
level of awareness about the documentation of the patients’ information. Shihundla, Lebese
and Maputle (2016) stated that giving hands on training of the nursing professionals about
documentation of patients’ information helps promote practice improvement under the in-
patient settings.
My second recommendation will be increasing stringency in the electronic medical
records in order to reduce the chances of medication documentation error and other practice
related information. Gagnon et al. (2016) stated that training of the nursing professional
under the presence of the doctors is helping in increasing the level of adherence and at the
same time helps to reduce the chances of the erroneous documentation of the patients;
information.
Conclusion

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Thus from the above analysis of the patient case report it can be clearly stated that there are
several discrepancies in the healthcare practice that violated that rules and regulations of the
The Joint Commission (TJC). (2014) Record of Care, Treatment, and Services. There are
error n documenting the name of the patient, patient’s age, insurance number and gap in
information in the consent form.
In order bring improvement in practice proper training and education of the nursing
professional is important. The training of the nursing professional must be given in the
presence of doctors and IT professionals in order to increase the level of awareness about
patients’ documentation and at the same time increasing the level of the adherence of EHRs
with proper proficiency.

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References
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Rousseau, M. (2016). Factors influencing electronic health record adoption by
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Gliklich, R. E., Dreyer, N. A., & Leavy, M. B. (Eds.). (2014). Registries for evaluating
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Shihundla, R. C., Lebese, R. T., & Maputle, M. S. (2016). Effects of increased nurses'
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The Joint Commission (TJC). (2014). Record of Care, Treatment, and Services Access date:
11th December 2019. Retrieved from: https://foh.psc.gov/tjc/roc/standards.pdf