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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