– IncompleteRecordsProjectGuidelinesSpring2022.docx

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The purpose of this Course Project is to apply the knowledge gained in analyzing various performance indicators of a hospital, analyzing trends, determining compliance or poor performance areas, and providing recommendations for improvement or solutions.


For this Course Project, you are asked to analyze a number of status reports for General Hospital, determine compliance with indicators provided to you, and provide suggestions or make recommendations for improvement where needed.

Data on the following indicators are provided in a Microsoft Excel document.

1. Release of Information Reports (ROI)

2. Record Completion: Physician Orders (PO)

3. Record Completion: History and Physical (H #038; P)

4. Record Completion: Discharge Summary (DC Summary)

5. Report Completion: Operative Report (OP Report)

6. Incident Reports (IR)

7. Standards

8. Rubric (grading rubric)

Part 1: Data Calculations, Standards, and Compliance Notes

Turn the General Hospital status data given for the month of January into meaningful information by performing the following.

Point Values

General Criteria

Specific Data Calculation, Standards, and Compliance Rate Components

40 points5 points for each type of calculation listed in the last column

Calculations necessary to find completion timeliness for the following on the next column

1. Release of information for all 20 requests (how many days it took to release the information requested)

1. Physician orders (how many days it took every physician to sign each of his or her orders)

1. History and physical dictation (how many days it took to dictate the H #038; P for each admission—subtract date of admission from the date of dictation)

1. History and physical transcription (how many days it took to transcribe the H #038; P—subtract date of dictation from the date of transcription)

1. Discharge summary dictation (how many days it took to dictate the DC for each admission—subtract date of discharge from the date of dictation)

1. Discharge summary signature (how many days it took to sign the DC—subtract date of discharge from the date signed)

1. Operative report dictation (how many days it took to dictate the OP report for each admission—subtract date of surgery from the date of dictation)

1. Operative report signature (how many days it took to sign the OP report—subtract date of surgery from the date signed)

 15 points

Standards* for the following on the next column

*Standards can be added in each worksheet applicable to the item being analyzed.

1. Completing ROI requests in the cases when records are on-site or off-site

1. Signing orders

1. Dictating a history and physical

1. Signing a discharge summary

1. Dictating an operative report

30 points5 points for each of the items listed in the last column

Compliance rates based on the standards identified for the following on the next column

1. ROI requests

1. Physician orders

1. Dictation of History and Physical

1. Signing of Discharge Summary

1. Dictation of Operative Report

85 points total

Meets all of the components listed above

Part 2: Report

Write a two-page report formatted as a memo detailing areas of noncompliance and at least three recommendations for improvement. The content of the report should be based on your prior calculations, highlights, and compliance notes from the prior analysis and other insight from analyzing the incident report, core measure, and meaningful use data. For full credit, the memo should include the following.

Point Value

Memo Components

10 points

Short introductory paragraph identifying the purpose and scope of the report

15 points

A paragraph highlighting areas that the hospital is in compliance with, including release of information, record documentation and completion, and incident reports. Paragraph should start with a summary sentence and then provide more details (including data) on each area the hospital is performing well.

25 points

A paragraph that addresses noncompliance, which should include the items below

· A summary of the areas of noncompliance.

· Any trends identified regarding a specific type of document (such as H #038; P or orders, certain physicians, core measures, etc.)

· Emphasis on two to three noncompliant items that are most serious or important in your opinion

· Clear details on all noncompliant items by using tables, graphs, or bullet points

25 points

A paragraph that explains at least three recommendations for improvement, which need to apply knowledge gained about performance improvement activities, tools, techniques, and information systems or other technology, as well as processes and working with people. Recommendations for improvement should be specific to issues identified in the prior paragraph.

5 points

Grammar and formatting. Memo format is required.

5 points

Content of the memo is well organized. Information in the paragraphs is well connected and supported with data. For exle, if you identify an area of non-compliance, it will be expected to provide a recommendation for improvement for that particular issue.

85 points

Meets all of the components listed above

Grading Rubric





Deliverable: Part 1

Part 1: Data Calculations, Standards, and Compliance Notes

Completion Timeliness Calculated for the Hospital


Calculations necessary to find completion timeliness for each of the items listed above

Compliance Standards Identified 


Standards for each item as listed above identified

Compliance Rates Calculated for the Hospital


Compliance rates calculated based on the standards identified for each item listed

Total points



Deliverable: Part 2

Part 2: Report



Short introductory paragraph identifying the purpose and scope of the report

 Areas of Compliance


Paragraph highlighting areas of compliance as described above

 Areas of Noncompliance


Paragraph addressing areas of noncompliance as described above



Minimum of three recommendations for improvement with justification

 Grammar and Formatting


Memo format is to be followed and writing should be free of grammar errors

 Organization and Cohesiveness


Content is well organized, connected, and supported by data.

Total points for Week 7






A quality project will meet or exceed all of the above requirements. 

Tools and Resources

· Access to Microsoft Word and Excel

· Professional memo template to use for your report

· All project-related documents available in Doc Sharing formatted as Word, Excel, or PDF files

· Access to the Internet

· Medicare Conditions of Participation requirements pertaining to documentation and clinical quality

· Meaningful Use Requirements for Hospitals, Stage 1

· HIPAA requirements in relation to release of information (ROI). A good resource to check out is

· The Joint Commission requirements pertaining to documentation, core measures, and national patient safety goals

Best Practices

· Remember that the goal is to practice good data management skills—understanding, calculations, comparisons, analysis, and evaluation.

· Read detailed instructions for each item (more than once) until you gain clarity, and ask the instructor early if you have any questions.

· Familiarize yourself with the various formats of data and use of formulas in Excel.

· Practice good critical thinking skills.

· Take clear and consistent notes as you are doing your calculations.

· Use all the resources provided to you and do extra research to gain clarity on the compliance standards for all areas of review.

· Practice good writing skills—clear and concise statements, well-organized details to support your findings, and justifications for your recommendations. 

Submitting Course Project Deliverables

Submit your assignment to Dropbox for it section.

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