Stan No Elemen Penilaian N

dar ur il
ut ai
1 The information needs of those who provide 1
MOI
clinical services are considered in the planning 0
1
process.
2 The information needs of those who manage the 1
hospital are considered in the planning process. 0
program and supports those staff with quality
and patient safety responsibilities throughout the
hospital (Also see SQE.1)
3 . The information needs and requirements of 1
individuals and agencies outside the hospital are 0
considered
in the planning process.
4 The planning is based on the hospitals size and 1
complexity. 0
MOI. 1 The hospital has a written process that protects 1
2. the confidentiality, security, and integrity of data 0
and information
2 The process is based on and consistent with laws 1
and regulations. 0
The process identifies the level of confidentiality 1
3
maintained for different categories of data and 0
information.
4 Those persons who need or have a job position 1
permitting access to each category of data and 0
information are identified.
5 1
Compliance with the process is monitored. 0
MOI 1 The hospital determines the retention time of 1
3 patient clinical records and other data and 0
information.
2 The retention process provides expected 1
confidentiality and security. 0
3 Records, data, and information are destroyed in a 1
manner that does not compromise confidentiality 0
and
 1
security 0
MOI 1 Standardized diagnosis codes are used and use 1
4 monitored. 0
2 Standardized procedure codes are used and use 1
monitored. 0
3 1
Standardized definitions are used. 0
4 Standardized symbols are used, and those not to 1
be used are identified and monitored 0
5 Standardized abbreviations are used, and those 1
not to be used are identified and monitored. 0
MOI 1 Data and information dissemination meet user 1
5 needs 0
2 Users receive data and information on a timely 1
basis process 0
3 Users receive data and information in a format 1
that aids its intended use. 0
4 Staff have access to the data and information 1
needed to carry out their job responsibilities. 0
MOI 1 . Health information technology stakeholders 1
6 participate in selection, implementation, and 0
evaluation of
information technology
2 Health information technology systems are 1
assessed and tested prior to implementation. 0
3 Health information technology systems are 1
evaluated following implementation for 0
usability,effectiveness,and patient safety
MOI. 1 1
Records and information are protected from loss.
7. 0
2 Records and information are protected from 1
damage or destruction. 0
3 Records and information are protected from 1
tampering and unauthorized access or use 0
MOI 1 Decision makers and others are provided 1
8 education on the principles of information use 0
and
 management.
2 The education is related to the data and 1
information needs of the individual and job 0
responsibilities.
3 Clinical and managerial data and information are 1
integrated as needed to support decision making. 0
MOI 1 There is a written guidance document that 1
9 defines the requirements for developing and 0
maintaining
policies, procedures, and programs, including at 1
least items a) through h) in the intent. 0
2 There are standardized formats for all similar
documents; for example, all policies.
3 The requirements of the guidance document are 1
implemented and evident in the policies, 0
procedures,
and programs found throughout the hospital.
MOI 1 Required policies, procedures, and plans are 1
9.1 available, and staff understand how to access 0
those
documents relevant to their responsibilities.
2 Staff are trained and understand those 1
documents relevant to their responsibilities. 0
3 The requirements of the policies, procedures, 1
and plans are fully implemented and evident in 0
the
actions of individual staff members
4 The implementation of policies, procedures, and 1
plans is monitored, and the information supports 0
full
implementation
MOI 1 A clinical record is initiated for every patient 1
10 assessed or treated by the hospital. 0
2 Patient clinical records are maintained through 1
the use of an identifier unique to the patient or 0
some
3 The specific content, format, and location of 1
 entries for patient clinical records is 0
standardized and
determined by the hospital.
MOI 1 Patient clinical records contain adequate 1
10.1 information to identify the patient. 0
2 Patient clinical records contain adequate 1
information to support the diagnosis. (Also see 0
AOP.1.1)
3 Patient clinical records contain adequate 1
information to justify the care and treatment. 0
(Also see
AOP.1.2)
4 Patient clinical records contain adequate 1
information to document the course and results 0
of treatment.
(Also see COP.2.1, ME 6; COP.3, ME 2; ASC.5; and
ASC.7)
MOI 1 The clinical records of all emergency patients 1
10.1 include arrival and departure times 0
.1 2 The clinical records of discharged emergency 1
patients include conclusions at the termination of 0
treatment.
3 The clinical records of discharged emergency 1
patients include the patients condition at 0
discharge
4 The clinical records of discharged emergency 1
patients include any follow-up care instructions. 0
MOI 1 Those authorized to make entries in the patient 1
11 clinical record are identified in hospital policy. 0
(Also see
IPSG.2)
2 There is a process to ensure that only authorized 1
individuals make entries in patient clinical 0
records
3 There is a process that addresses how entries in 1
the patient record are corrected or overwritten. 0
4 Those authorized to have access to the patient 1
clinical record are identified in hospital policy. 0
 5 There is a process to ensure that only authorized 1
individuals have access to the patient clinical 0
record.
MOI 1 The author can be identified for each patient 1
11.1 clinical record entry. 0
2 The date of each patient clinical record entry can 1
be identified. 0
3 The time of each patient clinical entry can be 1
identified 0
MOI 1 A representative sample of active and discharged 1
12 patient clinical records is reviewed at least 0
quarterly or
more frequently as determined by laws and
regulations.
2 The review is conducted by physicians, nurses, 1
and others authorized to make entries in patient 0
records
or to manage patient records.
3 The review focuses on the timeliness, legibility, 1
and completeness of the clinical record. 0
4 Record contents required by laws or regulations 1
are included in the review process. 0
5 . The results of the review process are 1
incorporated into the hospitals quality oversight 0
mechanism