HI305: Management of Health Information

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HI305: Management of Health Information essay assignment

Discussion Topic: State’s hospital licensing requirements

INSTRUCTIONS: Respond to all posts; response to classmates should be thoughtful and advance the discussion, response should make and/or frequent informed references to unit material or scientific literature, follow APA style if resources are used, 75 word minimum in response per post

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Every hospital that operates within the United States’ borders should be functioning under federal and state regulations and guidelines. NYS is no different, but it was tough to find the rules governing hospitals. This discussion is about comparing state regulations with federal laws. I chose to compare and contrast the “governing body” code because it is essential to establish responsibilities. The NYS regulation is covered under Title 10, section 405.2, titled Governing Body. This regulation outlines the organization and operation of a hospital (NYSDOH, 2017). It establishes specific responsibilities for some of the executive positions in the hospital (NYSDOH, 2017). The federal regulation for Governing Body is under Title 42, § 482.12 (CMS, 2017). These statues are very similar. The state is law is more than likely built off the federal. The federal statute is a little different in that it mandates that every Medicare patient is cared for by a doctor of medicine of osteopathy (CMS, 2017).


The Joint Commission requires facilities that they provide services to abide by National Patient Safety Goals. One of the areas that are covered is Ambulatory health. The Joint Commission established 2021 goals surrounding patient identity, medicine safety, infection prevention, and surgical mistakes (The Joint Commission, 2021). These safety goals are focused on maintaining and increasing patient safety. For example, correctly identifying patients will ensure you treat the correct patient (The Joint Commission, 2021). One way to prevent surgical mistakes is to mark the body part that needs to be operated on (The Joint Commission, 2021).

~Chad Welsh~


Each hospital should be under federal and state regulations and guidelines. I live in Michigan. We will be comparing federal and state law for hospitals. To become a hospital in Michigan you will need to start a licensure application for BCHS-HFD-100 and pay the applicable fees. Some hospitals may apply to participate in the Medicaid and Medicare programs however, the state must be licensed with the state before they can be licenses with CMS (The Centers of Medicare and Medicaid Services). The National Patient Safety Goals (NPSGs) are based on which area you work in such as ambulatory, behavior health, and home care. For 2021 in the ambulatory setting the goals are: identify patients correctly, use medicines safely, prevent infection, and prevent mistakes in surgery. These should be common practices in the healthcare field and our main focus. In order to identify patients correctly you would need to ask first and last name and date of birth. Using two patient identifiers is very crucial because in medicine there is room for error. I had two patients with the same first name and one was given the wrong medication by my coworker because she did not verify last name and date of birth. We hate to see these errors happen but unfortunately they occur frequently.

~Marissa Stockwell~

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