Health Information System
Identify the problem areas for the facility described below and prepare a written recommendation addressing a plan of correction for each site. You have been hired as a consultant for a behavioral health care facility comprising 11 client service sites. They are Joint Commission accredited and are anticipating a survey soon. After initial visits to each site, your analysis of deficiencies includes:
Site 1—Residential Chemical Dependency Program for Adolescents The medical records are well organized and in good or-der, but after closer inspection, you find that the physician responsible for completing physical exams does not assess clients’ motor skills, which is a requirement for adolescent admissions. You also find that although the history and physical is performed and dictated by the physician within 24 hours, the typed report does not appear in the chart for weeks.
Site 2—Residential Chemical Dependency Program for Adult Women the Joint Commission and state standards require that a master treatment plan be completed within 14 days of admission. A representative sample review of the facilities’ charts reveals no treatment plans. Upon closer scrutiny, you learn that none of the clients admitted in the past 3 months has a treatment plan in the charts either.
Site 3—Outpatient Mental Health Clinic with 600 Active Clients After conducting a study to determine the record re-trialability rate, it is learned that 75% of the records are inaccessible. The day the study was completed, only 40 clients had been scheduled for appointments. This location has only two health information clerks, and one has been pulled frequently to answer the phone at the intake desk.
Site 4—Outpatient Chemical Dependency Site with 125 Active Clients A quantitative analysis process has been set up and the record clerk trained, but no quantitative analysis has occurred. Upon a return visit to analyze the situation, it is found that the records clerk is also the office manager with responsibilities to answer the phone, schedule appointments, conduct financial intakes, maintain time sheets for clinicians, and complete general correspondence.
Site 5—Outpatient Chemical Dependency Site with 40 Active Clients Upon receiving a subpoena duces tecum and a court order, a clinical supervisor fails to notify the organization’s clinical director, health information manager, or an administrator. Instead, she takes the records home and asks her husband, who is an attorney, for advice.
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