Information Management Compliance.
Felicia Ntow
Western Governors University

Information Management Compliance
The hospital’s plan for information management encompasses the full spectrum of data generated and used by the organization in all various departments from housekeeping, laundry services, imaging, and pharmacy through to nursing. In order to provide cost-effective quality services, information must be accurate and communication of the information should be securely transmitted in a timely manner to the appropriate individuals on a need to know basis.
Compliance Status The Nightingale Community Hospital current compliance status is not meeting the standards of the Joint Commission.
RC.01.01.01
The hospital has just an admission orders form that does not define the components of a complete medical record.
The admission orders form does not contain the unique patient’s identification. It has just the patient name, and two or more people may have the same name. Wrong patient identification may be one of the reasons why there have been errors labeling patient specimens.
Although there is a place on the form to identify consults, there is no justification for the consult on the patient’s chief compliant and no admitting diagnoses recorded.
The medical record on hand does not contain information needed to justify the patient’s care, treatment and services. For example, there is no reason given for intake/output nor is there route for the intake (feeding tube, IV, or PO), or output (urinal, foley, stool, or colostomy).
The hospital is not in compliance because the medical record does not contain results of any type of diagnostic testing that support the course and result of the patient’s care, treatment and services.
The hospital does not promote continuity of care among providers. Although there is a case management consult that