The CEO of your accredited hospital indicates that your facility is due for an unannounced Joint Commission accreditation survey within the next six months and asks you to provide a report to him regarding the medical staff’s compliance with the requirements for delinquent records for last year.

Analysis and Charts/Graphs

• Best to use the graphs to show problem areas or interesting areas
• Look at the last 3 rows of your spreadsheet. How did your percent of delinquent records look – were they o.k.? All months? Total for year? If so, mention in your memo
• Look at the % of delinquencies due to H&Ps missing. Any months out of compliance? Total for year?
• Look at the % of delinquencies due to op reports missing. Any months out of compliance? Do you see a trend here? What about the total for the year?

Purpose of Memo

• Business document written to one or more people in a facility or group (e.g. Committee)
• Can be short – informative
• Can be more lengthy – informative, asking for input, or providing suggestions, etc.
• Usually not written on facility letterhead, although it can

Memo Guidelines

• Start with purpose of study – remind CEO of request
• Indicate standards or rules re incomplete records – be specific
• Difference between incomplete and delinquent record could be included – not required
• Analyze data – what months were out of compliance, how did we do for the year, etc.
• Use a table format, or bullets, or narrative.
• Refer to the included charts/graphs/tables
• Come up with plan of action.
• Can make up name for your administrator
• Can put your name and your position title (e.g. HIM Manager or Director)
• Make memo 1 ½ – 2 pages in length. 11 or so font, use professional font, not fancy.

Write a memo reporting your findings based on the graphs and analysis you completed in assignment 4. Memo should address the areas identified in the grading rubric below. Body of memo should include one summary table and two graphs that illustrate key findings.

Attached is the charts/graphs