Question

Northwest Ambulatory Surgery Center provides urology, endoscopy, orthopedic,

otolaryngology, and ophthalmology procedures. Physicians for each service are listed below.

The Center has a documentation requirement that every patient’s health record must have

an H&P prior to surgery. A data collection is being done to verify compliance with that

requirement.

1. Determine which data elements should be included in the data collection.

2. Create a data collection checklist to be used in the chart review.

Urology – Dr. Westerly, Dr. Columbia

Endoscopy – Dr. Southcliffe, Dr. Harvard, Dr. Cornell, Dr. Penn

Ophthalmology – Dr. Easton, Dr. Northrop

Orthopedic – Dr. Yale, Dr. Princeton

Otolaryngology – Dr. Princeton

In June, Northwest Ambulatory Surgery Center conducted a chart audit to determine

compliance with the H&P on the chart prior to surgery requirement. The results are as

follows:

A total of 1220 surgeries were performed in May:

640 endoscopies

160 urological procedures

240 ophthalmologic procedures

120 otolaryngology procedures

60 orthopedic procedures

100 total charts were reviewed:

Dr. Northrop 7 charts 6 with H&P 1 w/o H&P

Dr. Easton 22 22 with H&P

Dr. Westerly 33 30 with H&P 3 w/o H&P

Dr. Southcliffe 28 20 with H&P 8 w/o H&P

Dr. Penn 10 10 with H&P

Examine the results of the data collection and answer the following questions.

1. What deductions can be made about the data collection itself?

2. Propose a more meaningful data collection.

3. What deductions can be made regarding the results of the data collection? Create a graph to depict the data collection results

4. Based only on the data collection above, create a graphic design which illustrates the

missing H&Ps by service.

Answer 1

The History and Physicals (H&P) before surgery is vital steps for each and every health care organization. The surgeon performs a history and physical (H&P) /Pre-surgical assessment, to clear a patient for a scheduled surgery.

In the present scenario The Northwest Ambulatory Surgery Center where do the H&P as a standard procedure prior to surgery. Through the H&P the surgeon can come to know that the patient is clear for surgery or have had a significant change of status in the days before the surgery, which would require the surgeon to perform a more extensive evaluation. If it will follow as correctly can ease the reimbursement services.

1. The patient data collection requirements may vary according to the health care setting. The data elements to be collected in the

*Patient Identification

*Health Perception

*Self-perception

*Procedures and date and type of surgery

*Principal Diagnosis

*Lab results

*GeneralExamination and systematic examination

*Nutritional and metabolic pattern

*Elimination pattern

*Activity - exercise pattern

*Cognitive Patterns

*Sleep-rest pattern

*Value and beliefs

*Coping-stress tolerance

2. Patient Name :

Case NO#:

Age :

Weight :

Height :

Allergies:

Criteria	Meet/Not (put tick/x)
Anesthetic Risk and evaluation
Admission and pre-surgical Assessment :
*Patient Identification *Health Perception *Self-perception *Procedures and date and type of surgery *Principal Diagnosis *Specific Departmental consultation *Nutritional and metabolic pattern *Elimination pattern *Activity - exercise pattern *Cognitive Patterns *Sleep-rest pattern *Value and beliefs *Coping-stress tolerance

1. Here in the data collection chart audit, we can see the deduction in the data collection History and Physicals (H&P) of the patients (or presurgical assessment.

Out of 100 charts reviewed :

*Ophthalmologic Procedures: Out of 29 charts reviewed 1 without H&P

*Urology Procedures: out of 33 charts reviewed 3 without H&P reviewed *Endoscopy Procedures: out of 38 charts reviewed 8 without H&P reviewed

From each of the specialty procedures from the departments, such as ophthalmology, endoscopy, and urology there is a total deduction of 12 data collection was observed

2. As a surgeon, he has to perform a history and physical examination (H&P) to clear a patient for surgery to avoid and prevent complications. And it also helpful for the reimbursement process and also if in case the patients develop some significant changes before the surgery we can evaluate for the changes we can go for further decision making regarding the changes.

A pre-surgical H&P is a group of services can be done to the patients to avoid further complications of a procedure.

3.

4.