The Hospital Rules and Regulations for Medical Staff

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Healthcare institutions need to adhere to certain standards and regulations set by overseeing bodies. These standards were placed in order to ensure optimal performance from the healthcare institution’s staff, and ensure that their patients get the level of care and treatment they need. This paper’s goal is to reassess this hospital’s alignment to those set standards with the use of their guidelines for physician’s dictated reports as a base line, and make appropriate recommendations to either maintain or realign our focus when needed.

An assessment of the hospital’s rules and regulations for medical staff, in relation to our physician’s dictated reports

Overseeing bodies implement standards to healthcare institutions because the services they provide are critical to a person’s health and well-being. These institutions deal with people’s lives on a daily basis, and to improve and maintain a certain level of service and efficiency, overseeing health organizations impose certain regulations. This is supported by Wikipedia, in it’s article “Health care in the United States”, by stating “These regulations are designed to protect consumers from ineffective or fraudulent healthcare.” The main focus of this paper is to assess these standards set by multiple overseeing bodies, namely The state of Florida, The JCAHO, and Medicare, making use of the standard for physician’s dictated reports as a baseline, in order to make sure that our institution is complying and exceeding these organization’s expectations. Our main points of focus are as follows:

1. Contents and significance of the Physician’s dictated report

In providing healthcare to acute care inpatients

2. Summary of state of Florida standard, with respect to

physician’s dictated reports

3. The Medicare conditions of participation with relation to physician’s

dictated reports.

4. The JCAHO standards

5. The recommendations

Contents and significance of the Physician’s dictated report in providing

healthcare to acute care inpatients

According to http://www.transcription411.com, in their article “The SOAP Note”, a physician’s report would normally contain notes in a style known as “The SOAP note”. SOAP means, subjective, objective, assessment and plan. They use this style of noting down their observations and assessment of a patient’s condition. The physician dictated report is a recorded version of the report that a physician has made. One of the main points of significance of a dictated report is, this is the kind of communication used by doctors to medical transcriptionist in order for these transcriptionists to encode the patients last known medical assessment, treatment and health status into the hospital’s database. This is vital to acute care inpatients because these records are their status reports, and can be used by other physicians if needed, in order to provide accurate and appropriate healthcare. According to medword.com in their “Physician Dictation Guide” article, dictation is not the easiest of things to. It is a skill that must be practiced in order to get it right. It also mentioned that because medical schools expect new doctors to learn dictation skills on their own, the results are not as good as they should be. Because of this, the article lists down some dos and don’t s in dictation, such as, being ready with any papers before recording and learning about the equipment used for recording.

Summary of state of Florida standard, with respect to physician’s dictated reports

According to http://www.myflsunshine.com, in the Government-in-the-Sunshine Manual chapter called “What are the statutory exemptions relating to hospital and medical records? “ the paragraph called “Patient records” stated the following:

Patient medical records made by health care practitioners may not be furnished to any person other than the patient, his or her legal representative or other health care practitioners and providers involved in the patient’s care and treatment without written authorization except as provided by ss. 440.13(4)(c) and 456.057, F.S. Section 456.057(7)(a), F.S.

This guideline states that all patient medical records are confidential. Medical records include physician reports both written and recorded. This means that in order for our facility to follow State guidelines and avoid due sanctions, none of our patient records may be accessed by other individuals unless there is written consent by the patient. This makes the protection, transcription and documentation of patient medical records one of our top priorities, specially the physician dictated reports, as in their state, they can easily be accessed.

The Medicare conditions of participation with relation to physician’s dictated reports.

Medicare as defined in http://www.medicare.gov is a health insurance provided by the government that covers people aged 65 and above, as well as people of any age with certain disabilities or who have end-stage renal disease. They cover certain health costs and reimburse the healthcare facilities that provide them to a certain extent. According to http://www.seniorcorps.org in their article “Medicare Conditions of Participation” Medicare provides a certain set of rules to healthcare institutions to regulate how these institutions make use of Medicare aid. Adherence to these rules by CMS or Center for Medicare & Medicaid Services is a must for these facilities in order to get reimbursement. http://cfr.vlex.com discusses Medicare conditions of participation in relation to medical record services. There are many rules to follow but the main points to take into consideration that the hospital must have a department who’s responsibility is to maintain medical records. These records must be accurate, filed in a timely manner, dated, easily and securely accessible and you must be able to identify the author of these records. There is also a requirement to maintain the records original or legal copy for at least 5 years. These medical records include doctor’s notes, nurse interactions and verbal orders.

This paper’s conclusion will also make sure that the recommendations made will follow these guidelines strictly and will even exceed the guidelines to a doable extent.

The JCAHO standards

The JCAHO or the Joint Commission on the Accreditation of Healthcare Organizations, as defined by http://medical-dictionary.thefreedictionary.com, is an NPO, or non profit organization whose goal is to improve the healthcare services provided by institutions. They do this through accreditation and services that promote improvement. Since the JCAHO guidelines are only available for purchase on their website, this information on the guidelines for medical records came from the http://www.ehow.com article called “Facts on JCAHO Accreditation for Medical Records.” This article states in is “medical records” section that healthcare organizations must make sure that their medical records are stored in an area that is protected and secure In order to avoid unauthorized access. This means that all medical records must be kept secure and they must be locked or stored properly. We must ensure that this is followed to prevent fines or loss of accreditation.

The recommendations

After studying the 3 overseeing body’s guidelines, recommendations and rules, here are the following recommendations for hospital’s rules and regulations for its medical staff in relation to physician dictated reports:

The hospital will assign specific qualified individuals who will be assigned to tend to, and maintain medical records

All dictated records audio recordings must be sent for transcription immediately after being recorded in order to avoid being copied or heard by unauthorized individuals

All recordings must be done in a private and secure location, such as the physician’s private office with no unauthorized individuals in the same area

The records must not mention names and personal info about the patient when given to transcriptionists, and instead labeled with numbers and only associated to the patient’s personal information when in the database.

Use the SOAP method mentioned above to make sure that the reports are concise and accurate

Authorized users of the database where medical information is stored will be provided a password for access which cannot be shared with anyone and must be changed regularly.

The database must be locked at all time and only authorized medical records personnel will be allowed in.

No one is allowed to share the dictated reports to unauthorized personnel unless given written consent by both the patient and hospital administration.

All medical reports, both written and dictated must be approved by senior physicians for accuracy

All patient interactions must be recorded and imputed into the database within the week.

References

42 CFR 482.24 – Condition of participation: Medical record services. (October 01, 2010 ) cfr.vlex.com August 20, 2011, http://cfr.vlex.com/vid/482-condition-participation-record- 19811382

Banks, C. (2011). Facts on JCAHO Accreditation for Medical Records. WWW.Ehow.com. August 20, 2011. http://www.ehow.com/facts_5529356_jcaho-accreditation-medical-records.html

Government-in-the-Sunshine Manual. What are the statutory exemptions relating to hospital and medical records? (2011, January 14). www.myflsunshine.com, August 20, 2011 http://www.myflsunshine.com/sun.nsf/sunmanual/632BB593706B1035852566F3006EA5E6

Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). (2011) http://medical-dictionary.thefreedictionary.com August 20, 2011 http://medical-dictionary.thefreedictionary.com/JCAHO

Physician Dictation Guide. (2010) http://www.medword.com August 20, 2011, http://www.medword.com/dictation.html

The SOAP Note (2010) www.transcription411.com August 20, 2011, http://www.transcription411.com/soap.htm

What is medicare? (April 2008) http://www.medicare.gov August 20, 2011, http://www.medicare.gov/publications/pubs/pdf/11306.

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