Evaluation of data collection from transcription standpoint

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Question

As HIM director, concerns have been expressed to you by the head surgical nurse regarding the lack of H&Ps on patients' charts causing surgical delays. Since a patient is not permitted to go to surgery without an H&P on record, this is causing serious issues, including daily backlogs or cancellations. Patients are becoming angry and surgeons want something done to eliminate this issue.

1. Plan a data collection to assess the situation, selecting the relevant data elements to be included.

2. Identify any other information that may be pertinent to the evaluation of the data collection from the transcription standpoint.

3. Assume that the data collected identifies one particular physician who has this issue repeatedly. His surgeries are scheduled beginning at 6:00 a.m. and he routinely dictates the H&Ps starting at 5:50 a.m. What strategies can be developed to reduce the delays?

Reference no: EM133875653

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