Ongoing Records Review, Fifth Edition, is a must-have for every HIM director, supervisor, quality manager, and survey coordinator who wants to be sure their facilities are ready to take control of the ongoing records review process, comply with The Joint Commission's standards, and problem solve with fellow professionals. The Joint Commission paid unannounced surveys visits to two of Clark's hospitals in 2006. They were ready and their surveys were successful due to the teams sincere commitment to and use of the strategies Clark has developed through years of experience. In this book, she shares those strategies and tips with you so you'll be prepared, confident, and ready to welcome surveyors to your hospital. In addition to the preparation advice on unannounced surveys, Ongoing Records Review, Fifth Edition, is updated with new forms, checklists, and step-by-step instructions on how to maintain records according to The Joint Commission s standards. You ll not only understand what you have to do, you'll know how to do it. Meeting standards will no longer be a concern. You'll also find explanations of ongoing records review requirements, scoring expectations, a tool to help you conduct ongoing records review using patient tracers, and a discussion of the relationship between the National Patient Safety Goals and ongoing records review.

This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.

The new, fully updated Information Management and Record of Care, Seventh Edition, is a comprehensive guide to the most current Joint Commission standards, elements of performance for information management and record of care, and the survey process.

Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.