Specifically, the following critical elements must be addressed:

I. Submit your completed Patient Health Quality Review, evaluating the completeness and accuracy of the provided medical record.

II. Analysis of Health Record: To begin, you will perform an audit on selected medical health record to review and analyze, ensuring that the data required

for patient health management is complete.

A. Based on your review of the medical health record, analyze the contents for defining required patient health data elements:

i. Patient identification

ii. Past health issues

iii. Current health issues

B. Analyze the contents for completeness and accuracy in documenting individual events and encounters. Based on your analysis, define which

data elements are required for the following:

i. Recording patient’s vital signs

ii. Recording health events

iii. Recording medication administration

III. JCAHO: In this section, you will review the Joint Commission Standards as they relate to the health record.

A. Identify the data JCAHO routinely reviews for compliance with information management systems.

B. Evaluate where the record is complete and where it is missing data.

C. Based on the missing data, outline the JCAHO standards where the hospital is deficient.