All hospitals and other healthcare facilities have a responsibility of providing reliable, quality, fast, timely, and affordable services to patients. Therefore, the information management system is a crucial aspect needed by hospitals and other healthcare facilities to be able to carry out their services. Given that the medical records of patients are different, healthcare managers such as doctors and nurses have proposed that the nature of care services dispensed by a healthcare facility depend entirely on the quality of information available. The ability to capture information on patient outcomes as care services are administered is the most appropriate way to obtain accurate, comprehensive, and consistent data. Although this strategy is challenging due to the financial and ethical concerns involved, doctors and nurses can occasionally make use of prospective information that has already been gathered to improve care services (Berwick, 2005, p.316). For example, hospital-related injury occurrence and ulcer prevalence surveys are usually collected as a standard medical procedure to improve patient care and safety quality at the level of personal nursing units in several healthcare facilities (Clarke & Donaldson, 2007, p.10).
According to Clarke & Donaldson (2007), the quality and consistency of clinical data collected vary significantly. Doctors and nurses need to capture medical records on an electronic platform that facilitates simultaneous recording of appraisal data and interventions. This will allow accurate performance assessment in health care. Extensive use of information technology in healthcare facilities will not only improve the quality and safety of care services but also is expected to offer an efficient source of medical data that will be used as a reference point in care administration. Patients do not share the same medical risks; for example, chronically ill, elderly, physiologically unstable patients, and other patients enduring complex treatment have an elevated risk of encountering numerous types of unpleasant events in healthcare. Information on patient injuries may be constantly gathered for all in-patients. However, this information may be of little use for obstetrical patients, thus, doctors and nurses are required to understand the baseline hazards patients have for different negative results that they cannot mitigate. This knowledge should be integrated into research and assessment efforts via risk adjustment strategies which are generally in two stages: (1) cautiously describing the number of patients vulnerable to risks and (2) collecting dependable data concerning baseline risk factors and evaluating them. Therefore, the relationship between staffing and outcomes may be rendered useless in the absence of an effective risk adjustment strategy (Clarke & Donaldson, 2007, p.11).
As noted earlier, a health record is an important instrument used by doctors and nurses to offer quality care, mitigate illness and improve the health of patients. Health records are important in the quantitative analysis of care services. This information is later used to assess and improve the quality of patient health care services and treatment. Healthcare information enhances clinical research, care services, and medical knowledge. In addition, it is used to design healthcare public policy that includes; legislation, regulations, and accreditation. For example, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is a non-profit organization that certifies healthcare facilities. A healthcare facility must prove that it complies with the operating standards set by JCAHO for hospitals. The organization also certifies hospitals that provide services such as mental health care, long-term care, and ambulatory care (Pickett, 2003, p.2).
The Commission on Accreditation of Rehabilitation Facilities (CARF) also certifies health care facilities that offer rehabilitation services. Both JCAHO and CARF require that healthcare facilities keep and update medical records on regular basis. A healthcare facility can also be accredited for Medicaid and Medicare compensation via federal laws published by the Center for Medicare and Medicaid Services (CMS). As part of the JCAHO and CMS certification process, doctors and nurses are required to analyze regularly the regulations, rules, and policies related to health record obligations. The quantitative analysis includes an assessment of the adequacy, completeness, accuracy, suitability, and quality of documentation (Pickett, 2003, p.6).
The main goal of the quantitative analysis is to make sure that every medical record has adequate information on the patient’s illness, development and outcome of care, information on how the ordered tests and treatment are administered, and information about the notification and acknowledgment concerning the transfer of patient responsibility between doctors. The analysis should also include the competence of the medical record for the health care facility’s performance enhancement as well as the use of risk management strategies. The JCAHO standards require that all departments within a care facility must have an active quality enhancement process in place (Haux, 2004). This means that all professionals- human resource managers, medical staff, nurses- engaged in health care dispensation must be involved in the record analysis process (Pickett, 2003, p.6).
To adhere to JCAHO regulations concerning information management services, the medical staff body must specify its membership classes and describe qualifications that one must have to be granted clinical privileges. Doctors who aspire to be considered must make formal applications for either clinical privileges or medical staff members to a specific health care facility. Once granted the privileges of membership, the doctor is automatically liable for obeying rules set by the medical staff. The doctor must fill several sections of the medical record such as history, discharge summary, doctor’s orders, and progress notes. Other professionals are also expected to contribute to the documentation process. For example, nurses must document the same information using nursing progress notes, medication records, and graphic records. They may partner with social workers to design a discharge plan. In addition, the nutritional requirements of patients may be documented via dietary services. Therefore, all medical experts at the care facility add vital information to the medical record via progress notes (Pickett, 2003, p.7).
According to JCAHO, medical facilities must sequentially keep a record so that it can be easily understood by a third party. The medical files should be neatly arranged and professional language should be used to label them. If some recommendations must be displayed, they should be revealed in a suitable format. The progressive notes prepared by medical staff should be irrefutable and describe the matter appropriately. Entries should be dated and signed by the medical personnel who prepared them to ensure authenticity. If the note requires a countersignature by the head of the department, it should be captured within the medical staff regulations. For instance, if the medical regulations authorize rubber-stamps signatures to be used in validating progressive notes, their use must be limited. The person whose signature is duplicated on a stamp is required to attach a signed statement on the file (Pickett, 2003, p.8).
The Joint Commission requires that care facilities perform diagnostic testing and procedures as ordered by the patient. The requirements contained in the Provision of Care section of the Joint Commission accreditation requirements focus on planning, appraisal, continuous monitoring, and uninterrupted management of care administered to patients with acute ailments. Most of the Joint Commission’s requirements are bureaucratic. Some of these requirements can be supported by Cerner’s computerized prescriber order entry (CPOE). These include doctor/nurse documentation, clinical document viewing, and additional applications that boost direct patient care. The system (Cerner) offers content that can be used to perform an initial psychological health appraisal for any patient. This system also facilitates intermittent assessment of the mental health of patients since it is a requirement of the Joint Commission (Cerner Corporation, 2011, p.6).
The medical staff can use the Cerner system to direct clinical orders to precise workstations depending on the location of the patient, accessibility to the required medical instruments, and priority of the order. The system can offer practical assessment for explicit work requests to caution about probable overdue orders as a way of online supervision. Cerner’s system aids in a retrospective in giving out information concerning the turnaround time routine. The TAT monitor tracks a specimen from the moment it is admitted to the laboratory and ages specimens concerning the amount of time it takes in the lab. Stoplight coding is employed concerning the position of how a specimen moves toward being late (yellow) or is late (red). Thus, the Cerner system can be used to enhance the ability of medical staff to conform to the Joint Commission’s care accreditation requirements (Cerner Corporation, 2011, p.9).
Berwick, D. M. (2005). Broadening the view of evidence-based medicine. Qual Safety Health Care, 14, 315-316.
Cerner Corporation. (2011). Cerner Solutions and Joint Commission Provision of Care Accreditation Requirements. Web.
Clarke, S.P., & Donaldson, N.E. (2007). Chapter 25: Nurse Staffing and Patient Care Quality and Safety. Web.
Haux, R. (2004). Strategic information management in hospitals: an introduction to hospital information system. New York: Springer.
Pickett, F. (2003). Health Information Management and the Health Care Institution. Web.