UpdatedGeneralHospitalDatapart1.xlsx

Release of Info Reports (ROI)

HIT 226 Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with the Release of Information Standards. Areas of noncompliance should be identified as well as the standard. Hint: You may use your own state's Department of Health standards in addition to HIPAA requirements.
Release of Information Report for January 2014
	Date Received	Client Name	Requestor Name	Info Disclosed	Purpose of Disclosure	Date Disclosed	Records Offsite	Staff ID #	Completion Time	Standard	Compliance
1	1/1/14	Jones, Johnny	PCP	H & P	Continuity of Care	1/21/14	N	14571	20	30	10
2	1/4/14	King, Samantha	St. Lawrence	D/C Summary	Continuity of Care	1/17/14	N	14571	13	30	17
3	1/5/14	Piazza, Anthony	PCP	D/C Summary	Continuity of Care	2/8/14	N	25148	34	30	-4
4	1/9/14	Legend, Mary	Attorney	D/C Summary	Litigation	3/3/14	Y	25148	53	60	7
5	1/10/14	Stepnowski, Joseph	Robert Wood Johnson	X-rays	Continuity of Care	1/14/14	N	25148	4	30	26
6	1/11/14	Largent, Khalif	Mother	D/C Summary	At the request of the individual	2/28/14	N	14571	48	30	-18
7	1/11/14	Williams, Michael	PCP	H & P	Continuity of Care	1/17/14	N	14571	6	30	24
8	1/15/14	Teller, Aiden	PCP	D/C Summary	Continuity of Care	1/20/14	N	25148	5	30	25
9	1/17/14	Hower, Layla	Bayonne Medical Center	D/C Summary	Continuity of Care	2/26/14	N	14571	40	30	-10
10	1/18/14	Cartwright, Renee	Robert Wood Johnson	Lab reports	Continuity of Care	2/1/14	Y	14571	14	60	46
11	1/20/14	Perez, Stacey	PCP	X-rays	Continuity of Care	3/5/14	Y	25148	44	60	16
12	1/21/14	Santoso, Susan	Attorney	X-rays	Litigation	3/1/14	N	14571	39	30	-9
13	1/21/14	Williams, William	St. Lawrence	D/C Summary	Continuity of Care	1/28/14	N	14571	7	30	23
14	1/21/14	Abrams, Jonah	St. Lawrence	D/C Summary	Continuity of Care	4/5/14	N	25148	74	30	-44
15	1/25/14	Stern, Kimberly	Robert Wood Johnson	H & P	Continuity of Care	1/31/14	N	25148	6	30	24
16	1/25/14	Sran, Timothy	PCP	Lab reports	Continuity of Care	2/5/14	N	25148	11	30	19
17	1/27/14	Berger, Mark	PCP	X-rays	Continuity of Care	2/9/14	N	25148	13	30	17
18	1/28/14	Romano, Maria	Attorney	D/C Summary	Litigation	2/1/14	N	14571	4	30	26
19	1/31/14	Smith, Jennifer	St. Lukes	D/C Summary	Continuity of Care	3/3/14	N	14571	31	30	-1
20	1/31/14	Martinez, Alonso	PCP	D/C Summary	Continuity of Care	5/4/14	Y	25148	93	60	-33
					Release of Information
					Compliance	65%
					On Time	13
					Total	20

Record Completion (PO)

HIT 226 Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state's Department of Health standards.
Physician Order Report for January 2014
Physician : Dr. Jones					Physician: Dr. Johns					Physicians: Dr. Huffman					Physician: Dr. Patrikus					Physician: Dr. Leiberman
Client Medical Record #: 123456					Client Medical Record #: 987654					Client Medical Record #: 654789					Client Medical Record #: 321789					Client Medical Record #: 741852
Date of Admission: 1/6/14					Date of Admission: 1/7/14					Date of Admission: 1/10/14					Date of Admission: 1/18/14					Date of Admission: 1/28/14
Date of Discharge: 1/9/14					Date of Discharge: 1/9/14					Date of Discharge: 1/15/14					Date of Discharge: 1/18/14					Date of Discharge: 2/2/14
Date of Order	Date Signed	# of Days	Standard	Compliance	Date of Order	Date Signed	# of Days	Standard	Compliance	Date of Order	Date Signed	# of Days	Standard	Compliance	Date of Order	Date Signed	# of Days	Standard	Compliance	Date of Order	Date Signed	# of Days	Standard	Compliance
1/6/14	1/6/14	0	1	1	1/7/14	1/9/14	2	1	-1	1/10/14	1/10/14	0	1	1	1/18/14	1/21/14	3	1	-2	1/28/14	1/28/14	0	1	1
1/6/14	1/6/14	0	1	1	1/7/14	1/9/14	2	1	-1	1/10/14	1/10/14	0	1	1	1/18/14	1/21/14	3	1	-2	1/28/14	1/28/14	0	1	1
1/6/14	1/7/14	1	1	0	1/7/14	1/9/14	2	1	-1	1/10/14	1/10/14	0	1	1	1/18/14	1/21/14	3	1	-2	1/28/14	1/28/14	0	1	1
1/7/14	1/7/14	0	1	1	1/7/14	1/9/14	2	1	-1	1/10/14	1/11/14	1	1	0						1/29/14	1/29/14	0	1	1
1/7/14	1/7/14	0	1	1	1/8/14	1/9/14	1	1	0	1/11/14	1/11/14	0	1	1	Compliance	0%				1/30/14	1/30/14	0	1	1
1/8/14	1/8/14	0	1	1	1/8/14	1/9/14	1	1	0	1/12/14	1/13/14	1	1	0	On Time	0				1/30/14	1/30/14	0	1	1
1/9/14	1/10/14	1	1	0	1/9/14	1/9/14	0	1	1	1/12/14	1/13/14	1	1	0	Total	3				1/31/14	1/31/14	0	1	1
					1/9/14	1/9/14	0	1	1	1/12/14	1/13/14	1	1	0						2/1/14	2/1/14	0	1	1
Compliance	100%									1/12/14	1/13/14	1	1	0						2/2/14	2/2/14	0	1	1
On Time	7				Compliance	50%				1/13/14	1/15/14	2	1	-1						2/2/14	2/2/14	0	1	1
Total	7				On Time	4				1/14/14	1/15/14	1	1	0
					Total	8				1/15/14	1/15/14	0	1	1						Compliance	100%
																				On Time	10
										Compliance	92%									Total	10
										On Time	11
										Total	12

Record Completion (H & P)

HIT 226 Course Project – Data Analysis and Identification of Noncompliance – Due in Week 6, day 7 (Sunday midnight)
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state's Department of Health standards.
History and Physical Report for January 2014
	MR #	Physician	Date of Admission	Date Dictated	Date Transcribed	Date Signed	# of days	Standard	Compliance	# of days	Standard	Compliance
1	789321	Leiberman	1/4/14	1/4/14	1/4/14	1/5/14	0	1	1	1	1	0
2	456321	Huffman	1/4/14	1/5/14	1/5/14	1/5/14	0	1	1	1	1	0
3	741852	Patrikus	1/6/14	1/7/14	1/8/14	1/8/14	1	1	0	2	1	-1
4	963321	Johns	1/7/14	1/7/14	1/7/14	1/10/14	0	1	1	3	1	-2
5	144558	Huffman	1/10/14	1/10/14	1/11/14	1/11/14	1	1	0	1	1	0
6	695852	Leiberman	1/10/14	1/10/14	1/10/14	1/10/14	0	1	1	0	1	1
7	124536	Huffman	1/12/14	1/12/14	1/12/14	1/13/14	0	1	1	1	1	0
8	379152	Leiberman	1/15/14	1/16/14	1/16/14	1/16/14	0	1	1	1	1	0
9	685982	Jones	1/16/14	1/16/14	1/16/14	1/17/14	0	1	1	1	1	0
10	558844	Jones	1/17/14	1/17/14	1/17/14	1/18/14	0	1	1	1	1	0
11	415287	Johns	1/20/14	1/22/14	1/22/14	1/24/14	0	1	1	4	1	-3
12	919125	Patrikus	1/20/14	1/20/14	1/20/14	1/22/14	0	1	1	2	1	-1
13	744445	Patrikus	1/21/14	1/21/14	1/21/14	1/25/14	0	1	1	4	1	-3
14	111111	Patrikus	1/21/14	1/21/14	1/21/14	1/22/14	0	1	1	1	1	0
15	145281	Huffman	1/26/14	1/26/14	1/27/14	1/27/14	1	1	0	1	1	0
16	144417	Leiberman	1/26/14	1/26/14	1/26/14	1/27/14	0	1	1	1	1	0
17	695833	Patrikus	1/27/14	1/27/14	1/27/14	1/31/14	0	1	1	4	1	-3
18	335588	Johns	1/28/14	1/31/14	1/31/14	2/2/14	0	1	1	5	1	-4
19	457924	Jones	1/31/14	1/31/14	1/31/14	2/1/14	0	1	1	1	1	0
20	414519	Huffman	1/31/14	1/31/14	1/31/14	2/1/14	0	1	1	1	1	0
								Dictation			Transcription
								Compliance	100%		Compliance	65%
								On Time	20		On Time	13
								Total	20		Total	20

Record Completion (DC Summary)

HIT 226 Course Project – Data Analysis and Identification of Noncompliance – Due in Week 6, day 7 (Sunday midnight)
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state's Department of Health standards.
Discharge Summary Report for January 2014
	MR #	Physician	Date of Discharge	Date Dictated	Date Transcribed	Date Signed	# of Days	Standard	Compliance	# of days	Standard	Compliance
1	789321	Leiberman	1/7/14	2/1/14	2/1/14	2/15/14	25	30	5	39	30	-9
2	456321	Huffman	1/8/14	1/29/14	1/30/14	2/10/14	21	30	9	33	30	-3
3	741852	Patrikus	1/10/14	1/17/14	1/18/14	1/19/14	7	30	23	9	30	21
4	963321	Johns	1/28/14	2/8/14	2/8/14	2/10/14	11	30	19	13	30	17
5	144558	Huffman	1/12/14	1/29/14	1/29/14	2/28/14	17	30	13	47	30	-17
6	695852	Leiberman	1/11/14	1/31/14	1/31/14	2/12/14	20	30	10	32	30	-2
7	124536	Huffman	1/18/14	2/15/14	2/15/14	2/21/14	28	30	2	34	30	-4
8	379152	Leiberman	1/17/14	2/7/14	2/8/14	3/1/14	21	30	9	43	30	-13
9	685982	Jones	1/19/14	1/19/14	1/20/14	1/21/14	0	30	30	2	30	28
10	558844	Jones	1/18/14	1/25/14	1/25/14	1/28/14	7	30	23	10	30	20
11	415287	Johns	1/21/14	1/24/14	1/25/14	1/31/14	3	30	27	10	30	20
12	919125	Patrikus	1/26/14	1/31/14	2/1/14	2/15/14	5	30	25	20	30	10
13	744445	Patrikus	1/24/14	2/4/14	2/4/14	2/6/14	11	30	19	13	30	17
14	111111	Patrikus	1/23/14	1/26/14	1/26/14	1/31/14	3	30	27	8	30	22
15	145281	Huffman	1/28/14	1/31/14	1/31/14	3/8/14	3	30	27	39	30	-9
16	144417	Leiberman	1/31/14	2/28/14	2/28/14	3/4/14	28	30	2	32	30	-2
17	695833	Patrikus	2/1/14	2/15/14	2/15/14	2/21/14	14	30	16	20	30	10
18	335588	Johns	2/1/14	2/15/14	2/15/14	2/19/14	14	30	16	18	30	12
19	457924	Jones	2/10/14	2/10/14	2/11/14	2/12/14	0	30	30	2	30	28
20	414519	Huffman	2/6/14	2/7/14	2/7/14	4/1/14	1	30	29	54	30	-24
								Dictation			Signature
								Compliance	100%		Compliance	55%
								On Time	20		On Time	11
								Total	20		Total	20

Record Completion (OP Report)

HIT 226 Course Project – Data Analysis and Identification of Noncompliance – Due in Week 6, day 7 (Sunday midnight)
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state's Department of Health standards.
Operative Report for January 2014
	MR #	Physician	Date of Operation	Date of discharge	Date Dictated	Date Transcribed	Date Signed	Dictation Completion	Standard	Compliance	Signature Completion	Standard	Compliance
1	789321	Leiberman	1/4/14	1/6/14	1/4/14	1/4/14	1/7/14	0	1	1	3	30	27
2	456321	Huffman	1/5/14	1/6/14	1/5/14	1/5/14	1/6/14	0	1	1	1	30	29
3	741852	Patrikus	1/6/14	1/10/14	1/7/14	1/7/14	1/7/14	1	1	0	1	30	29
4	963321	Johns	1/8/14	1/10/14	1/8/14	1/8/14	1/8/14	0	1	1	0	30	30
5	144558	Huffman	1/10/14	1/15/14	1/10/14	1/10/14	1/11/14	0	1	1	1	30	29
6	695852	Leiberman	1/10/14	1/11/14	1/12/14	1/12/14	1/13/14	2	1	-1	3	30	27
7	124536	Huffman	1/13/14	1/16/14	1/13/14	1/13/14	1/14/14	0	1	1	1	30	29
8	379152	Leiberman	1/15/14	1/18/14	1/17/14	1/17/14	1/19/14	2	1	-1	4	30	26
9	685982	Jones	1/16/14	1/20/14	1/17/14	1/17/14	1/20/14	1	1	0	4	30	26
10	558844	Jones	1/18/14	1/25/14	1/20/14	1/20/14	1/27/14	2	1	-1	9	30	21
11	415287	Johns	1/21/14	1/23/14	1/22/14	1/22/14	1/22/14	1	1	0	1	30	29
12	919125	Patrikus	1/20/14	1/26/14	1/21/14	1/21/14	1/21/14	1	1	0	1	30	29
13	744445	Patrikus	1/22/14	1/23/14	1/22/14	1/22/14	1/23/14	0	1	1	1	30	29
14	111111	Patrikus	1/21/14	1/28/14	1/21/14	1/21/14	1/21/14	0	1	1	0	30	30
15	145281	Huffman	1/27/14	1/28/14	1/27/14	1/27/14	1/27/14	0	1	1	0	30	30
16	144417	Leiberman	1/26/14	1/30/14	1/31/14	1/31/14	2/2/14	5	1	-4	7	30	23
17	695833	Patrikus	1/28/14	1/30/14	1/28/14	1/28/14	1/29/14	0	1	1	1	30	29
18	335588	Johns	1/28/14	1/31/14	1/29/14	1/29/14	1/29/14	1	1	0	1	30	29
19	457924	Jones	1/31/14	2/5/14	1/31/14	1/31/14	2/10/14	0	1	1	10	30	20
20	414519	Huffman	2/1/14	2/3/14	2/1/14	2/1/14	2/2/14	0	1	1	1	30	29
									Dictation			Signature
									Compliance	80%		Compliance	100%
									On Time	16		On Time	20
									Total	20		Total	20

Incident Reports (IR)

HIT226 Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Analyze the data in terms of the 2014 Hospital National Patient Safety Goals, by The Joint Commission. Identify three areas for improvement that the hospital should focus on during February and discuss in Part 2 of the Course Project.
Incident Report for January 2014
Type of incident	Number of incidents	Standard	Compliance
Falls from bed	15	NPSG.06.01.01
Falls from toilet	8
Medication error	9
Allergic reaction	19	***
Blood transfusion reaction	2
Hospital acquired infections	12	NPSG.07.01.01
Surgical errors	1

Core Measure

HIT226 Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Analyze the data to determine compliance with Core Measure requirements. Problem areas should be identified in relation to the national average and minimum expected and discussed in Part 2 of the Course Project. N/A – means that the data is not available due to not being collected. Minimum expected means that the hospital definitely needs to meet this requirement.
Core Measure Report for January 2014 – MI & CHF (Myocardial Infarction & Congestive Heart Failure)
Heart Attach Care	General Hospital	National average	Minimum expected	Heart Failure Care	General Hospital	National average	Minimum expected
Average number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital	57	59		Heart Failure patients given discharge instructions	94%	94%	80%
Average number of minutes before outpatients with chest pain or possible heart attack got an ECG	9	7		Heart Failure patients given an evaluation of left ventricular systolic (LVS) function	100%	99%	80%
Outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival	N/A	57%		Heart Failure patients given an ACE inhibitor or ARB for left ventricular systolic dysfunction (LVSD)	95%	97%	80%
Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival	95%	96%	80%
Heart attack patients given fibrinolytic medication within 30 minutes of arrival	N/A	58%
Heart attack patients given PCI within 90 minutes of arrival	94%	96%	80%

Meaningful Use

HIT 226 Course Project; Hospital Data Analysis and Reporting
The data below is from General Hospital. Analyze the data to determine compliance with Meaningful Use Requirements Stage 1 for Eligible Hospitals and discuss in Part 2 of the Course Project. Hint: Use Eligible Hospital and Critical Access Hospital (CAH) Attestation Worksheet for Stage 1 of the Medicare Electronic Health Record (EHR) Incentive Program, provided as a separate document in doc sharing.
Selected Meaningful Use Measures for January 2014
Selected Meaningful Use Measures	General Hospital	Standard	Compliance
Percentage of patients that had at least one medication order entered through the CPOE	50%	30%	Met
The eligible hospital or CAH has enabled the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period	No	Yes	Not Met
Percentage of patients who had at least one entry (or an indication that the patient has no known medical allergies) recorded as structured data	50%	80%	Not Met

Standards

Standard list based on CMS & The Joint Commission Guidelines and requirements
Activity	Standard	Notes
Release of information for records stored onsite	30 days	Needed for Part I of the project
Release of information for records stored offsite	60 days	Needed for Part I of the project
Signing physician orders	24 hours	Needed for Part I of the project
Dictating History and Physical	24 hours from admission (1 day)	Needed for Part I of the project
Transcribing History and Physical *	24 hours from dictation date (1 day)	Needed for Part I of the project	* This is a hospital policy, not a CMS or TJC standard
Dictating Discharge Summary	30 days from D/C date	Needed for Part I of the project
Signing Discharge Summary	30 days from D/C date	Needed for Part I of the project
Dictating Operative Report	24 hours from surgery (1 day)	Needed for Part I of the project
Signing Operative Report	30 days from D/C date	Needed for Part I of the project
Incident report	Identify standard in the NPSG – separate document	These are needed for Part II of the project
Core Measures	Minimum expected and national average are provided in the spreadsheet	These are needed for Part II of the project
Meaningful Use	Standards provided in the Hospital Attestation Stage 1 Worksheet – separate document	Needed for Part I of the project

Rubric

Grading Rubric for Part I
Calculations	5 points for each type of calculation (40 pts total)
ROI – days to release
PO – signature
H & P – dictation
H & P – transcription
D/C – dictation
D/C – signature
OP – dication
OP – signature
Subtotal	0
Standards	5 points each for matching and identifying the following standards (15 points total):
ROI, H&P, OP, & D/C
Meaningful Use (MU Stage 1) – Percentage of patients that had at least one medication order entered through the CPOE
Meaningful Use (MU Stage 1) – Percentage of patients who had at least one entry recorded as structured data
Subtotal	0
Compliance Rates	5 points each (30 pts total)
ROI
PO
H & P
D/C
OP
Meaningful Use
Subtotal	0
total (85 possible)	0

UpdatedGeneralHospitalDatapart1.xlsx

UpdatedGeneralHospitalDatapart1.xlsx

Release of Info Reports (ROI)

Record Completion (PO)

Record Completion (H & P)

Record Completion (DC Summary)

Record Completion (OP Report)

Incident Reports (IR)

Core Measure

Meaningful Use

Standards

Rubric

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