b.
c.
d.
Assist the Hospital to ensure that important processes and activities to improve performance and patient safety are measured, assessed, and spread systematically across all disciplines throughout the Hospital;
Participate as requested in identifying and managing sentinel events and events that warrant intensive analysis; and
Participate as requested in the Hospital’ s patient safety program including measuring, analyzing, and managing variation in the processes that affect patient care to help reduce medical / healthcare errors.
1.2.4 Information Management a. Review and evaluate medical records to determine that they: i.
ii.
Properly describe the condition and progress of the patient, the quality of medical histories and physical examinations, the therapy, and the tests provided along with the results thereof, and the identification of responsibility for all actions taken; and
Are sufficiently complete at all times so as to facilitate continuity of care and communication between all those providing patient care services in the Hospital. b.
c.
Develop, review, enforce, and maintain surveillance over enforcement of medical staff and Hospital policies and rules relating to medical records including completion, preparation, forms, and format and recommend methods of enforcement thereof and changes therein; and
Provide liaison with Hospital administration, nursing service, and medical records professionals in the utilization of the Hospital on matters relating to medical records practices and information management planning.
1.2.5 Emergency Preparedness
Assist the Hospital administration in developing, periodically reviewing, and implementing an emergency preparedness program that addresses disasters both external and internal to the Hospital.
1.2.6 Strategic Planning a.
Participate in evaluating existing programs, services, and facilities of the Hospital and medical staff; and recommend continuation, expansion, abridgment, or termination of each;
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