JCI Educational

JCI Educational
Conference
Conference
Al
Al
-
-
Noor Specialist Hospital
Noor Specialist Hospital
February 21
February 21
-
-
23, 2006
23, 2006
Assessment of Patients
Assessment of Patients
(AOP)
(AOP)
Introduction
Primary Processes
Collect information and data on the patients
physical, psychological, social status, and health
history
Analyzethe data and information to identify the
patients health care needs; and
Developa plan of care to meet the patients
identified needs
Performed by Qualifiedindividuals
Introduction
An effective patient assessment process results
in decisions about the patients immediate
and continuing treatment needs, even when
the condition changes.
It is a continuous, dynamic process that takes
place in many settings and consists of three
primary processes:
Collecting information (physical, psychological, social, & health
history)
Analyzing the information to identify health care needs; and
Developing a plan of care to meet the identified needs.
Introduction
Patient assessment is appropriate when it
considers:
patients condition,
age,
health needs, and
his or her requests or preferences; and
is most effective when the various
responsible health professionals work
together.
Assessment Topics
Initial Assessments
Scope, Content, Settings, Time Frame,
Documentation, Competency, and Uniformity
Special Populations
Reassessments
Laboratory Evaluations
Timely Diagnostics
Hazardous Materials
Diagnostic Radiology
Inter-Disciplinary Collaboration
Patient Need Prioritization
Initial Assessments
AOP.1- 1.4: All patients cared for by the
organization have their health care needs
identified through an established
assessment process. Organization policy
and procedure:
Define the information to be obtained for
inpatients and ambulatory patients
Define who performs the assessment
Identifies the information to be documented
as the patient enters the organization
Initial Assessments
Organization assessment policy and
procedure:
Based on applicable domestic laws and
regulations
Completed in the time frame prescribed by the
organization, except:
Medical: w/in 24 hrs and before surgery or anesthesia
Readily available to those responsible for the
patients care
Initial Assessment - Content
AOP.2 Each patients initial assessment
includes a physical examination and
health history.
Interpretation: Hospital policy needs to be clear as to
the content of a physical assessment, what portions may be
deferredto a later time, or deferred to another practitioner.
For example, if permitted by hospital policy, an admitting
consultant can defer pulmonary system assessment to the
anesthesia assessment conducted by the anesthesiologist.
The overall process must result in a complete assessment,
per hospital policy, recorded on the patients record before
surgery and anesthesia, or within 24 hours of admission.
August 2003
Initial Assessment - Settings
Issue: need to be in a policy or can various
assessment forms identify, for different settings (e.g.,
ambulatory or in-patient) or different patients (e.g.,
adult, pediatric), the required scope and content?
Interpretation:The list in the Survey Process Guide covers all types of
written documents, including forms. The most important issue is that, as the
measurable elements require, the scope and content of each type of assessment
is defined in writing. To satisfy this requirement, a form would need to be
clear as to;
the health professional(s) responsible for completing the form or each
section, and
the minimal content for the form to be considered complete in terms of
the required assessment scope and content.
Thus, a form will usually require guidelines for completion. Such guidelines
can be on the form, or in a separate policy. The form, with guidelines, is
needed to fully meet the standards.
J une 2004
Required Assessments
Who Will Perform - Where?
In-patient Out-patient Same Day
Ambulatory
Surgery
Emergency
Room
Recovery
Room
Pain (COP 19) SW
Values/Beliefs
(Religion) (PFE 1.1)
SW SW SW SW NR
History (AOP 2)
Physical (AOP 2)
Psychological (AOP 2) SW SW NR
Social (AOP 2) SW SW NR
Economic (AOP 2) SW SW NR
Learning needs (PFE 1.1) SW SW SW NR
Language (PFE 1.1) SW SW NR
Nutritional risk (AOP 2.2) SW SW NR
Functional risk (AOP 2.2) SW SW NR
Discharge needs (AOP 2.4) SW SW SW NR
Other ,( e.g. pediatric head
circ, immunizations)
SW=Documented at least once in the patients record and available at
subsequent visits, but, not required for each visit.
NR =Not Required
Initial Assessment Time Frame
AOP.1.3 Assessments are completed in the time
frame prescribed by the organization.
Appropriate time frames for performing assessments
are established for all settings and services.
Assessments are completed within the time frames
established by the organization.
The findings of assessments performed outside the
organization are verified at admission.
AOP.2.1.4 The initial nursing assessment is
documented in the patients record within the time
frame established by the organization.
Initial Assessment Time Frame
AOP.2.1.1 The initial medical assessment is
documented in the patients record within
the first 24 hours after the patients entry.
The initial medical assessment is documented in
the patients record within the first 24 hours of
admission.
Initial medical assessments conducted outside the
organization are no older than six months.
Any significant changes in the patients condition
since the report are noted in the patients record.
Initial Assessment Surgery
AOP.2.1.2 The initial medical assessment is
documented before the use of anesthesia or
surgical treatment.
Surgical patients have a medical assessment performed
before surgery and documented before surgery.
Results of diagnostic tests recorded before surgery.
Preoperative diagnosis recorded before surgery.
The anesthesia assessment determines if the patient is an
appropriate candidate for the planned anesthesia.
Patients are reevaluated immediately before the induction of
anesthesia.
An anesthesia assessment note is recorded before the use of
anesthesia.
Initial Assessment - Surgery
COP.10 Each patients surgical care is
planned and documented, based on the
results of the assessment.
The surgical care of each patient is planned.
The planning process considers all available
assessment information.
The planned surgical care is documented.
A preoperative diagnosis is documented.
Initial Assessment - Surgery
Issue: the preoperative diagnosis and postoperative
diagnosis are, in most cases, the same are there any
options for recording a postoperative diagnosis, such as
an exception process when only a different diagnosis is
recorded?
Interpretation: The options related to recording the
postoperative diagnosis along with the surgical findings
include:
rewrite the preoperative diagnosis as a postoperative
diagnosis,
write same along with the findings of the surgery,
use preprinted template forms for common surgeries and only
note exceptions to what appears on the form, or
Initial Assessment - Surgery
Interpretation:
develop a hospital policy and procedure that permits
documentation by exception in the absence of preprinted
template forms.
With an exception process, and whenever there is a
preliminary or tentative diagnosis, hospital
procedure identifies how a final diagnosis is recorded,
in particular when the results of pending laboratory or
other tests change an admitting or preoperative
diagnosis.
J une 2004
Initial Assessments Time Frames
In-patient Out-patient Same Day
Emergency
Room
Physician 24 Hours
Nurse
Physical
Therapist
Respiratory
Therapist
Nutritionist
Social Worker
Discharge
Planner
Initial Assessment - Emergent
AOP.2.1.3 The initial medical assessment
of emergency patients is appropriate to
their needs and conditions.
For emergency patients, the medical assessment
is appropriate to their needs and condition.
If surgery is performed, there is at least a brief
note and preoperative diagnosis recorded before
surgery.
Initial Assessment - Emergent
MOI.2.1.1 The clinical record of every
patient receiving emergency care includes:
1. the time of arrival,
2. the conclusions at termination of treatment,
3. the patients condition at discharge, and
4. any follow-up care instructions.
Initial Assessment
Special Populations
AOP.2.3 The organization conducts individualized
initial assessments for special populations cared for
by the organization.
very young patients;
frail elderly;
terminally ill and others in pain;
patients suspected of drug and/or alcohol dependency
victims of abuse and neglect.
COP.5.8 Policies and procedures guide the care of
vulnerable elderly patients and of children.
Initial Assessment - Documentation
AOP.1.4 Assessment findings are
documented in the patients record. and are
readily available to those responsible for
the patients care.
AOP.2.1 The patients medical and nursing
needs are identified from the initial
assessment.
Initial Assessment - Competency
AOP.4 Qualified individuals conduct the
assessments and reassessments.
1. Individuals qualified to conduct patient
assessments and reassessments are identified
by the organization.
2. Emergency assessments are conducted by
individuals qualified to do so.
SQE.3:
Qualified: matches the requirements of the
position with the qualifications of the
prospective staff member.
Initial Assessment - Uniformity
COP.1 Policies and procedures and
applicable laws and regulations guide the
uniform care of all patients.
1. The organizations clinical and managerial
leaders collaborate to provide uniform care
processes.
2. When similar care is provided in more than
one setting, care delivery is uniform.
Initial Assessment - Uniformity
Uniform patient care is reflected in the
following:
Access to and appropriateness of care and
treatment do not depend on the patients ability
to pay or the source of payment;
Acuity of the patients condition determines
the resources allocated to meet the patients
needs;
The level of care provided to patients (for
example, anesthesia care) is the same
throughout the organization; and
Patients with the same nursing care needs
receive comparable levels of nursing care
throughout the organization.
Initial Assessment - Scopes for
Discipline and Setting
In-
patient
Out-
patient
Same
Day
Ambulatory
Surgery
Emergency
Room
Immediately
Prior to
Induction
Recovery
Room
Special
Populations
**
Physician
Nurse
Therapist
Respiratory
Therapist
Nutritionist
Social
Worker
Discharge
Planner
Pharmacist
Re-Assessments - progress notes
AOP.3 All patients are reassessed at
appropriate intervals for their condition
A physician reassesses patients daily during the
acute phase of their care and treatment
to determine their response to treatment
and to plan for continued treatment or discharge
reassessments are documented in the patients
record.
Problems with Reassessments
Survey methods include staff interviews and
review of documents (policies and procedures,
and/or active and closed patient records.
Survey Findingsinclude:
Only 50% compliance
Compliance issues included poor policy
development and implementation (ME #5);
and inconsistent compliance with the policies.
Progress Notes
Issue: Physicians are to assess acute care patients on a
daily basis. What patients are considered acute
Interpretation: Each organization must determine
which types of patients are considered acute (both
medical and psychiatric). rarely a clear transition
point it would be logical to consider that patients still
undergoing initial assessment, and patient for whom the
course of care has not yet been determined, are still in
need of daily physician attention, as opposed to normal
delivery, elective oral and maxillo-facial surgery, and
others.
Surveyors will examine both the policy and practice. In
particular, the evaluation of patient records is useful to
determine that the required physician oversight occurred.
Date: September 2002
Progress Notes
Issue: Frequency of the reassessment process for acute
and non-acute patients. (AOP.3)
Interpretation: All patients are reassessed daily
during the acute phase of their care. Hospital policy
identifies those patient groups considered acute. Non-
acute patients are assessed at a frequency consistent with
good clinical practice.
Hospital policy can define a specific frequency for
reassessment of these patients, or
can set a range, consistent with what the Medical Advisory
Board considers good practice. (Each physician can then
decide the frequency of reassessment based on this range, and
consistent with the condition of his or her patient.)
Date: August 2003
Re-Assessments Time Frames
In-patient Out-patient Same Day
Emergency
Room
Recovery
Room
Physician Daily
Nurse
Physical
Therapist
Respiratory
Therapist
Nutritionist
Social Worker
Discharge
Planner
Laboratory & Radiology
Available
AOP.5.1 (6.1) Clinical pathology
(diagnostic imaging) services are provided
by the organization to meet patient needs
or are readily available through
arrangements with outside sources.
AOP.5.12 (6.10) The organization has
access to experts in specialized diagnostic
areas when necessary.
Laboratory & Radiology
Timely
AOP.5.4 (6.4) Laboratory (Radiology) results
are available in a timely way as defined by the
organization.
Established expected turn-around times
Time frames designed to meet patient needs
ACC.1.4 Diagnostic tests for determining
patient need are completed and used as
appropriate to determine whether the patient
should be admitted, transferred, or referred.
Laboratory & Radiology - Safety
AOP.5.2 (6.2) A laboratory (radiology)
safety program is in place, followed, and
documented.
support compliance with applicable standards and
regulations
handling and disposal of infectious and hazardous
materials
availability of safety devices
the orientation of all staff to safety procedures and
practices
in-service education for new procedures hazardous
materials.
Laboratory & Radiology - Safety
FMS.5 The organization has a plan for the
inventory, handling, storage, and use of
hazardous materials and the control and
disposal of hazardous materials and waste.
handling, storage, and use
inventory of hazardous materials and waste;
reporting and investigation of spills, exposures, and
other incidents;
proper disposal of hazardous waste;
proper protective equipment and procedures during
use, spill, or exposure;
documentation, including any permits, licenses, or
other regulatory requirements
proper labeling of hazardous materials and waste.
Laboratory & Radiology - Quality
AOP.5.11 The organization regularly
reviews quality control results for all
outside sources of laboratory services.
Even if it is an Accredited laboratory
QPS.3.2 Clinical monitoring includes
laboratory & radiology safety and quality
control programs.
QPS.3.6 Clinical monitoring includes use
of blood and blood products.
Radiation Safety
AOP.6.2 A radiation safety program is in
place, followed, and documented.
applicable standards, laws and regulations;
handling and disposal of hazardous materials
availability of appropriate safety protective devices
orientation
continuing in-service education
QPS.3.2 Clinical monitoring includes
radiology safety and quality control
programs.
Inter-Disciplinary Collaboration
AOP.7 Medical, nursing, and other individuals
and services responsible for patient care
collaborate to analyze and integrate patient
assessments.
A patient benefits most when the staff responsible
for the patient works together to analyze the
assessment findings and combine this information
into a comprehensive picture of the patients
condition. From this collaboration, the patients
needs are identified, the order of their importance
is established, and care decisions are made.
Inter-Disciplinary Collaboration
ACC.2.2 Information about the patients
care and response to care is shared
among medical, nursing, and other care
providers during each staffing shift,
between shifts, and during transfers
between units.
COP.2.4 Each care provider has access
to the patient care notes recorded by
other care providers, consistent with
organization policy.
Patient Need Prioritization
AOP.7.1 The most urgent or important
care needs are identified.
Formal treatment team meetings, patient
conferences, and clinical rounds may be
appropriate for patients with complex or unclear
needs. The patient, his or her family, and others
who make decisions on the patients behalf are
appropriately included in the decision process.
ACC 1.1 Patients with emergency or
immediate needs are given priority for
assessment and treatment.
Questions?
Comments?
Discussion?
JCI Educational
JCI Educational
Conference
Conference
Al
Al
-
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Noor Specialist Hospital
Noor Specialist Hospital
21
21
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23 February 2006
23 February 2006
S
taff Qualifications and
taff Qualifications and
Education (SQE)
Education (SQE)
Staff Qualifications &
Education
Coordinated, uniform & efficient process to
recruit, evaluate, appoint & retain qualified
staff to fulfill mission & meet patient needs:
Planning Staffing
Process to identify job requirements & match
staff with patient needs
Planning Staffing
SQE.3
Process to identify job requirements & match
staff with patient needs:
Planning Staffing
SQE.4.
Collaborative process by leaders to develop
written staffing plan using accepted method:
Orientation & Education
SQE.5
Process developed to assure orientation for
new staff, contract workers & volunteers:
Orientation includes
General orientation to organization
Role of individual in organization
Specific responsibilities of job/position
Safety & reporting of medical errors
Infection control practices
Organization policies/ procedures
Orientation & Education
SQE.6
Process for staff to advance skills/knowledge
through documented education/ training:
Training is relevant to staffs ability to
meet patient needs
Resources to support staff education
and training
Training in resuscitative
techniques
SQE.6.1 SQE.6.1.1
Staff who provide patient care and others
defined by organization
Evidence is documented
Desired level of training is repeated every
two years
Orientation & Education
SQE.6.2
Assess staff ongoing learning needs based on
available data and develop organizational plan
Medical Staff
SQE.7
Effective process to gather, verify & evaluate
credentials of medical staff as primary person
responsible for patient care/ outcomes:
Evaluate qualifications & privileges permitted
by law/regulation & organization
Medical Staff
SQE.7, ME.3
Process to authorize admitting privileges to
care for patients based on qualifications:
Document physicians credentials in file &
verify using original source
Medical Staff
SQE.8
Process to authorize individuals to admit
and care for patients
Licensure, education, training, and
experience are used to authorize
Services to be provided are made known
Medical Staff
SQE.9
MS participate in organizations quality
improvement activities
Performance of individuals is reviewed
when indicated by quality improvement
activities
Performance of individual MS is reviewed
periodically, as established by
organization
Nursing Staff
SQE.10
Effective process to gather, verify & evaluate
credentials & qualifications of nursing staff
to provide direct patient care:
Evaluate qualifications permitted by law/
regulation & organization
Nursing Staff
SQE.10 and SQE.11
Effective process to gather, verify & evaluate
credentials & qualifications of nursing staff
to provide direct patient care:
Document nurses credentials in file & verify
from original source
Assign clinical work based on credentials
Nursing Staff
SQE.12
Nursing staff participate in organizations
quality improvement activities
Performance is reviewed when indicated
by findings of quality improvement
activities
Other Health Professional Staff
SQE.13
Effective process to gather, verify & evaluate
credentials of other health professional staff
to provide patient care & services:
Evaluate qualifications permitted by law/
regulation & organization
Other Health Professional Staff
SQE.13 and SQE.13.1
Effective process to gather, verify & evaluate
credentials of other health professional staff
to provide patient care & services:
Document credentials in file & verify from
original source, e.g.
Nurse Midwives,
Pharmacists & pharmacy technicians
Surgical assistants
Emergency medical specialists
Traditional healers & alternative medical
practitioners (acupuncture, herbal medicine)
Other Health Professional Staff
SQE.15
Other Health Care Professionals participate
in organizations quality improvement
activities
Questions?
Comments?
Discussion?
JCI Educational
JCI Educational
Conference
Conference
Al
Al
-
-
Noor Specialist Hospital
Noor Specialist Hospital
February 21
February 21
-
-
23, 2006
23, 2006
S
taff Qualifications and
taff Qualifications and
Education (SQE)
Education (SQE)
Staff Qualifications &
Education
Coordinated, uniform & efficient process to
recruit, evaluate, appoint & retain qualified
staff to fulfill mission & meet patient needs:
Planning Staffing
Process to identify job requirements & match
staff with patient needs
Planning Staffing
Process to identify job requirements & match
staff with patient needs:
Planning Staffing
Collaborative process by leaders to develop
written staffing plan using accepted method:
Orientation & Education
Process developed to assure orientation for
new staff, contract workers & volunteers:
Orientation includes
General orientation to organization
Role of individual in organization
Specific responsibilities of job/position
Safety & reporting of medical errors
Infection control practices
Organization policies/ procedures
Orientation & Education
Process for staff to advance skills/knowledge
through documented education/ training:
Orientation & Education
Process for staff to advance skills/knowledge
through documented education/ training:
Assess staff ongoing learning needs based on
available data & develop organizational plan
Medical Staff
Effective process to gather, verify & evaluate
credentials of medical staff as primary person
responsible for patient care/ outcomes:
Evaluate qualifications & privileges permitted
by law/regulation & organization
Medical Staff
Process to authorize admitting privileges to
care for patients based on qualifications:
Document physicians credentials in file &
verify using original source
Nursing Staff
Effective process to gather, verify & evaluate
credentials & qualifications of nursing staff
to provide direct patient care:
Evaluate qualifications permitted by law/
regulation & organization
Nursing Staff
Effective process to gather, verify & evaluate
credentials & qualifications of nursing staff
to provide direct patient care:
Document nurses credentials in file & verify
from original source
Assign clinical work based on credentials
Other Health
Professional Staff
Effective process to gather, verify & evaluate
credentials of other health professional staff
to provide patient care & services:
Evaluate qualifications permitted by law/
regulation & organization
Other Health
Professional Staff
Effective process to gather, verify & evaluate
credentials of other health professional staff
to provide patient care & services:
Document credentials in file & verify from
original source, e.g.
Nurse Midwives,
Pharmacists & pharmacy technicians
Surgical assistants
Emergency medical specialists
Traditional healers & alternative medical
practitioners (acupuncture, herbal medicine)
Other Health
Professional Staff
Effective process to gather, verify & evaluate
credentials of other health professional staff
to provide patient care & services
Other Health
Professional Staff
Effective process to gather, verify & evaluate
credentials of other health professional staff
to provide patient care & services:
Participate in quality management &
improvement activities, as needed
Questions?
Comments?
Discussion?
Establishing Accreditation
Scoring Process and Decisions
Key principles of scoring
methodology
Measurable and objective standards
Prioritize standards
Scoring strategy easily understandable
Key principles of scoring
methodology
Aggregate scoring rules to distinguish
organizational performance
Decision rules for non-clear situations
Scoring guidelines for evaluators and
organizations for consistency
J CI STANDARDS
368 Standards in 11 Functional areas
198 Core standards
170 Non-core Standards
1035 Measurable Elements (ME)
599 MEs of core standards
436 MEs of non-core standards
J udging & Scoring
Met
Partially Met
Not Met
Not Applicable
Data Sources
Achievements
Observations
Total Score
SCORING OF STANDARDS
Each Measurable Element is scored
10 (full compliance),
5 (partial compliance) or
0 (no compliance)
For each Standard, the score is the
average of all Measurable Elements of
the Standard
SCORING OF STANDARDS
All Core Standard scores are averaged
for an Aggregate Core Standard Score
All Non-core Standard scores are
averaged for an Aggregate Non-core
Standard Score
Scoring Rules
Track record required for scoring full
complianceor Met: Successfully
implemented
Initial Surveys
4 month track record
Triennial Surveys
12 month track record
Scoring Rules
Partially Met: Implemented but no track
record and is sustainable in minds of
surveyors
Not Met: Not Implemented
J udging & Scoring
Track Record
Process Implemented for Required Period
(Documented 4 months initial survey or 12 months for
tri-annual survey)
Fully Meets the Standard
Process Implemented with Improvements
Over Time
New Process is Judged to be Sustainable
Fully Meets the Standard
Questionable if New Process is Sustainable
(needs evidence)
Partially Meets
J udging & Scoring
Track Record
Meet Standard Most of the Time, but not
Always
Standard Expects 100% Compliance, or is High
Risk Activity
Partially or Does not Meet
Standard Does Not Demand 100% Compliance,
or is Low Risk
Partially Meets
Not Implemented, No Evidence, or Not
Sustained
D N t M t
Scoring Rules
Accredited: This decision results when an
organization meets the following conditions:
The organization demonstrates acceptable
compliance with all core standards.
Acceptable compliance is:
At least a score of 5on all core standards, and
No more than one 0in the measurable
elements of a core standard, and
An aggregate score of 9on core standards.
Scoring Rules
The organization demonstrates acceptable
compliance with all non-core standards.
Acceptable compliance is:
An aggregate score of 7on non-core standards.
Any required follow-up requirements have been
met.
Scoring Rules
Accreditation Denied: This decision results
when an organization meets one or more of
the following conditions at the end of the 6
month follow-up period to a full
accreditation survey, or the end of the 2
month follow-up period for a triennial
survey.
One or more core standard is scored less than
a 5.
Two or more measurable elements of a core
standard are scored 0.
The aggregate score for core standards is less
than 9
Scoring Rules
This decision results when J CI withdraws
the accreditation of an organization or when
the organization voluntarily withdraws from
the accreditation process.
FOLLOW-UP REQUIREMENTS
FOR
CORE STANDARDS
Accreditation is deferred and a written follow-
up report and/or a focused survey is
required if any Core Standard has:
more than one Measurable Element scored a
0(no compliance) or
a score for the Standard of less than 5.
FOLLOW-UP REQUIREMENTS
FOR
NON-CORE STANDARDS
Accreditation may or may not be deferred
and a written follow-up report and/or a
focused survey is required if any Non-core
Standard has:
A non-core standard scored 0,
that is, all of its Measurable Elements are
scored 0 (no compliance).
FOLLOW-UP PROCESS
Written report is required within 6 months for
standards that require:
a plan, policy or procedure, or
documentation.
surveyor observation, staff or patient
interviews, or the inspection of the
physical facility.
If both are required, written report is
reviewed at time of focused survey.
A single 3 month extension may be given at
f f
Summary of ACCREDITATION
DECISIONS
Accredited (all of three conditions are
met)
Acceptable compliance with all Core
Standards
Acceptable compliance with all Non-core
Standards
All Follow-up conditions are met
Summary of ACCREDITATION
DECISIONS
Accreditation denied
Any one or more of three conditions are not
met
The hospital withdraws from process once it
was initiated
J CI Board withdraws accreditation for cause
Summary - ACCEPTABLE
COMPLIANCE WITH CORE
STANDARDS
At least a score of 5 on all (each) core
standards
No more than one 0in the Measurable
Elements of any one core standard
An Aggregate Score of 9.0 or more on core
standards
Summary - ACCEPTABLE
COMPLIANCE WITH NON-
CORE STANDARDS
An aggregate score of 7.0 or more
Issues in scoring strategies
Consistent application of scoring strategy
Complex decision rules, hard to apply
Guidelines for Evaluators
Report Writing
Report Writing &
Documentation
Describe Data Sources Used
Clearly Describe How and Why
Organization Did Not Fully Meet the
Standard
Report Writing &
Documentation
Supportive Documentation -
Quantitative when Possible
4 of 6 clinical staff interviewed
In 7 of 10 open records and 3 of 5 closed
records reviewed, the admission assessment
was not done within 2 hours from the
patients time of arrival. In 2 of the records,
there was no documented provisional
diagnosis.
Report Writing &
Documentation
Give Credit For Progress Made
Try to Include a Positive Comment
Staff were not trained on the standard.
VS
The process was clearly
interdisciplinary, and included all of the
necessary elements, but staff were not
able to identify the policy.
Report Writing &
Documentation
Be clear and concise: hospital knows
exactly what they need to do to meet
the standard
Legible with Appropriate Grammar
Report Writing &
Documentation
Specify Data Source(s)
Staff Interviews, Patient Interviews, Open
Journal/Record Reviews
Recognize Achievements
The hospital has recently hired a new
clinical officer to address a staffing shortage
which affected the hospitals ability to
assess patients in a timely manner.