Appropriate Quality Code Patient Data Management & Documentation Case Study

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Chapter 17:

For this assignment I wanted to give you some more information on the SER (service) abbreviations and clarifications regarding instructions for the case study assignment on page 362:

Service (SER)

CD – Cardiology

EN – Endocrinology

GS – General Surgery

OB – Obstetrics

UR – Urology

OR – Operation Room

OP- this should be OR – Operation Room

NE – Neurology

Figure 17.6 – Data for timeliness of documentation study Pg 362

Refer/Read Case Study on page 361

During the last accreditation survey, the hospital had findings related to quality and timeliness of documentation. The facility is due for another survey very soon, To ensure that your organization is in compliance with the Joint Commission documentation standards, you need to conduct a quality audit. You have assigned one of your staff to collect data from patient records to accomplish this task. The staff member collected data for the month of December for quality and timeliness of documentation. The data collected are presented in figure 17.6 (found on pate 362).

Refer to the links below to become knowledgeable of The Joint Commission requirements on timeliness of History and Physicals and Operative Reports. (Links to an external site.) (Links to an external site.)

(Links to an external site.)

1. Analyze the collected data in Figure 17.6.

2. Assign the appropriate quality code (1-4), if applicable, for each patient using the key provided at the bottom of Figure 17.6 page 362. If no quality code is applicable enter NA for that patient. Also, document the reason that quality code was assigned. This portion of the assignment is work 42 points. 1 point for each correct quality code assigned and 1 point for the correct reason documented for patients #2-22. I have given you the answer to pt. #1.

There will be some data that was gathered that reflects all elements were meet, you can put N/A or Ok on those. If procedure start and end time is not filled in that may or may not play a part in you assigning the appropriate quality code or identifying that no quality issues was indicated.

Below is an example of how you are to submit the “Quality Code” and “Reason” for each patient by utilizing a table format.


Discharge Date


Quality Code






No time noted on H&P update stamp

3. Analyze the data:

a. Which code is most common? 1 pt.

b. Is there one service that seems to be a problem? 1 pt

c. What can you conclude from the data about compliance with documentation standards? 2 pts

4. Recommend what measures would need to be implemented to correct any documentation compliance issues? 4 pts

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