PC EP 2 & 6 PC EP 4 & 5

Transcription

1 Record Review Inpatient Only 3/10/2016 Data Definition Tool The Tracer Packet is to be completed in each inpatient unit by the manager or designee on a monthly basis. It is suggested that the manager does not complete a packet for his/her own area. Tracers are due on the last day of the month following the review (example: July Tracer due July 31). Instructions: Indicate Yes, No, NA (Not Applicable) for each question below. Inpatient Units: Monitor at least 1 patient record per month using the Tracer Record Review Inpatient Tool. Standard Location YES ADMISSION 1 Medical Record Number: 2 Initial nursing history completed within 24 hours of admission EP 2 & 6 HED: 1) Admission History tab (nurseries); 2) StarPanel starform for all Inpt. units that document in HED except nurseries; 3)StarPanel PDF of VPIMS Periop Nursing documentation for Periop staff; 4) StarPanel PDF for Cath Lab Nursing documentation; 5)paper record Admission /History/ Discharge form if completed during downtime or by an area where none of these electronic options is available. All components completed & signed by RN w/in timeframe as indicated on (1) Time of Medipac transaction to admit; (2) Time order written in CPOE; or (3) Time on Nursing Admission History 3 Provider history and physical (H&P) completed and. (May use previous H&P within 30 days prior or 24 hours after admission or registration that includes an update. The update includes an examination and any changes to the patient's condition.) & 5 H& P form or Star Panel H&P time on record w/in appropriate timeframes which are up to 24 hrs including: Previous H&P within 30 days prior or 24 hours after admission or registration that includes an update. The update includes an examination and any changes to the patient's condition.

2 4 Nursing physical assessment completed on admission? PC EP 6 Assessment/Intervention tab age appropriate First assessment completed w/in 8 hrs of admit time as indicated on (1) Time of Medipac transaction to admit; (2) Time order written in CPOE; or (3) Time on Nursing Admission History 5 Functional screen complete? PC ; EP 8 6 If functional screen positive, plans for follow-up PC Nutritional screen complete PC ; EP 7 8 Pain screen complete PC EP1 & 2 9 If pain screen positive, plans for follow-up PC EP 23; PC Abuse screen complete PC If abuse screen positive, plans for follow-up 12 Suicide Risk screen completed (including the environment) for patients with primary diagnosis of emotional or behavioral disorders? PC , 6, & 7 NPSG ) Admission History StarForm in StarPanel for units that chart in HED (nurseries do not complete Functional Screen on newborns); 2) paper admission history if completed in area that does not document in HED Admission History Admission History/Discharge Plan Nursing Assessment in HED Nursing Assessment in HED Admission History Admission History age appropriate tab VPH documents suicide risk screen in HED. In other areas, it's part of safety assessment in age appropriate assessment interventions tab. Functional Screen complete within 24 hours. Positive screen & provider contacted, MD notified as free text note. NA=negative screen OR preexisting condition (i.e., blind, cerebral palsy, or ADHD) Nutritional screen completed within 8 hours Pain screen completed within 8 hours Positive screen follow up of initial screen completed or negative screen = NA Social Work screen completed; NA is inappropriate answer for inpatients Positive screen & check in "social work ordered" box or negative screen = NA Patients with emotional or behavioral disorder diagnosis has completed assessment. (Children's 8C when applicable and all VPH) 13 If Suicide Risk screen positive, follow-up includes NPSG. provider assessment and environmental assessment Learning needs/education screen complete PC NA is inappropriate answer for inpatients., 4 & 5 15 Preferred language for discussing health care. PC VPH - in suicide screen section. Other HED areas - in Safety interventions. Provider assessment would be in StarPanel. Admission History tab (IP) In admission history Nursing environmental assessment and provider assessment is. Learning needs completed within 8 hours Documented

3 16 Discharge planning initiated within 24 hours of admission Alcohol and Substance Abuse Disorders 17 Assessment includes the following: * patient's religion and spiritual beliefs, values and preferences; * living situation; * leisure and recreational activities; * military service history; * peer group; * social factors; * ethnic & cultural factors; * financial status; * vocational or educational background; * legal history; * communication skills. 18 Assessment includes the following: * history of physical or sexual abuse as either the abuser or the abused; * Sexual history and identification; * Childhood history; * Emotional and health issues: * Visual - motor function; * Self-care. PC PC PC EP 6 19 Assessment includes the patient's family PC circumstances including the composition of the family EP 7 group and the need for their participation in the patient's care. Emotional and Behavioral Disorders 20 Assessment includes the following: * patient's religion and spiritual beliefs, values and preferences; * living situation; * leisure and recreational activities; * military service history; * peer group; * social factors; * ethnic & cultural factors; * financial status; * vocational or educational background; * legal history; * communication skills. PC Plan of Care VPH Psychosocial Assessment & VPH Nursing Admission History & Psychiatric Admission Evaluation (starpanel) and/or Crisis Assessment (paper record) VPH Psychosocial Assessment & VPH Nursing Admission History & Psychiatric Admission Evaluation (starpanel) and/or Crisis Assessment (paper record) VPH Pscyhosocial Assessment and Psychiatric Admission Evaluation (Starpanel) VPH Psychosocial Assessment & VPH Nursing Admission History & Psychiatric Admission Evaluation (starpanel) and/or Crisis Assessment (paper record) Plan initiated w/in timeframe or Case Management & Socical Work screen negataive

4 21 Assessment includes the following: * history of physical or sexual abuse as either the abuser or the abused; * Sexual history; * Childhood history; * Emotional and healthcare issues: * Visual - motor function; * Self-care. 22 Assessment includes the following: * patient's family circumstances including the composition of the family group; *Community Resources currently used by the patient; and *The need for their participation in the patient's care. PC EP4 PC VPH Psychosocial Assessment & VPH Nursing Admission History & Psychiatric Admission Evaluation (starpanel) and/or Crisis Assessment (paper record) VPH Pscyhosocial Assessment and Psychiatric Admission Evaluation (Starpanel) 23 Assessment includes the following: * Psychiatric evaluation; * Pscyhological assessments including intellectual projective neuropsychological and personality testing; * Complete neurological examination, when indicated. PC EP6 Psychiatric Admission Evaluation (Starpanel) ADVANCE DIRECTIVES (IP Only) 24 Advance Directives Progress Notes (MC# 4137) signed and completed? 25 Copy in chart or substance of directive in physician's progress notes or on Advance Directives Progress Notes (MC#4137) RC RI EP 9 RI EP 9 & 11 Advance Directives Progress Notes and HED Admission / History Extended Data (both completed) Clear plastic advance directive sleeve at the front of the chart (1st item) or on Advance Directives Progress Notes or physician progress notes or scanned in star panel under legal documents and in HED Adm/History extended data Both Advance Directives Progress Notes form and HED data completed to be Yes. Choice of: - Copy present or directive signed by physician OR - Copy in STAR Panel from previous admission under "ALL" and then "legal Documents" OR - Answer "NA" if patient has no Advance Directive

5 NURSING ASSESSMENT (IP Only) 26 Physical assessment per shift or unit standard? PC EP 23; 27 Each patient is reassessed as necessary based on his or her plan for care or changes in his or her condition. 28 Pain assessment at least every shift; when there is a change in patient condition or primary caregiver. PC Interventions r/t pain management are PC Pain is reassessed after administration of pain med/comfort measures PC PATIENT EDUCATION 31 Pain management addressed, as appropriate PC All "teaching/education" fields complete, as appropriate (excluding pain management) 33 Documentation by all disciplines involved in the patient's care, treatment or services. MEDICATION ADMINISTRATION 34 "Do Not Use" Abbreviations are NOT found in the MR on date of review? 35 Supporting documentation (diagnosis, condition, or indication for use) exists for every order for "current" medications. PC PC IM MM EP 9 Assessment/Intervention age appropriate tab Assessment/Intervention age appropriate tab Assessment/ Intervention age appropriate or Pain tab Assessment/Intervention age appropriate tab or Pain tab Assessment/Intervention age appropriate tab or pain tab and/or Controlled Drug Record HED Education Tab Education Record "other" or HED Education Tab Same as above. Paper and individual discipline notes; Electronic documentation available via OPC Assessment Section. All entries in the medical record on date of review including medication orders, MAR, problem list, flowsheets, progress notes,etc. Physician orders, H&P, progress notes Date, nurse signatuare & title, time and initials are and check mark placed beside "Standards Met" or "Except as Noted" for each section. Date, nurse signatuare & title, time and initials are and check mark placed beside "Standards Met" or "Except as Noted" for each section. Time, Date, Pain Score/indicators are Interventions, post time, relief, initials are. Interventions, date time, pain score, and initials are within 2 hrs of intervention. Exception: PCA or continuous infusion IV analgesia assessment every 4 hrs. All teaching fields specific to pain are completed. All teaching fields are appropriately completed except pain management teaching. Signature(s) & initials are present for appropriate disciplines. No " Do Not Use" abbreviations are found in the medical record on the date of review. Diagnosis, condition or indications for use are anywhere in the medical record including the H&P

6 36 Are orders for PRN medications specific such that there is no therapeutic duplicatoin (multiple options for a specific indication? Medications list Review patient's current PRN medication orders for therapeutic duplication. There should not be two orders that have the same instructions for when to administer (e.g., prn pain, prn nausea, prn for agitation).

7 DISCHARGE (IP Only) 37 Discharge plan reviewed every 24 hours. PC Discharge instructions completed upon discharge. PC EP 8 39 For patients admitted with primary diagnosis of emotional or behavioral disorders, discharge instructions include suicide prevention information such as crisis hot line number. OPERATIVE & OTHER PROCEDURES NPSG Consent form present and signed, dated and timed? RI Provider history and physical (H&P) completed and prior to procedure? (May use previous H&P within 30 days prior or 24 hours after admission or registration that includles an update. The update includes an examination and any changes to the patient's condition.) Plan of Care tab 1) Discharge Process tool document saved to StarPanel. 2) Paper Discharge Instructions sheet scanned into StarPanel if pt. discharged during HEO/Wiz downtime or Discharge Process tool not used. WIZ or paper Patient Discharge Instructions or discharge letters per speciality Consent Form H& P form Check box on Plan of Care/Discharge Plan tab for "done" Discharge letter complete and in StarPanel Discharge instructions includes suicide prevention information consent form present and signed, dated and timed H&P on record prior to procedure/ surgery and w/in appropriate timeframes: 42 Pre-procedural education before operative or high-risk procedures or before moderate or deep sedation or anesthesia. 43 Patient's condition is re-evaluated before administering moderate or deep sedation or anesthesia. PC PC EP 8 44 Pre-procedure checklist is completed. UP EP 2 45 "Time Out" before procedure. UP Preop Nursing Record (PDF in Starpanel) Sedation & Analgesia Record, Anesthesia record Pre-procedure checklist Area Specific documentation systems. Sedation/ Analgesia form. Documented ASA class and Pre-Sedation Status completed for moderate or deep sedation. For OR area Anesthesia Care Record ASA score prior to induction completed. All fields completed, as appropriate. Completed including date and time.

8 46 Immediate Post Operative/procedural Note is present RC and includes the following: EP 7 1. Name of surgeon, proceduralist and assistants; 2. Procedure(s) performed and description of the procedure; 3. Findings; 4. Estimated blood loss; 5. Specimen(s) removed, if any. 6. Postoperative diagnosis. Post surgical progress notes All elements are in the record before the patient moves to the next level of care irregardless of physical location. Exception: if the proceduralist accompanies the patient from the procedure room to the next level of care, the note can be written in that unit or area of care. 47 The Operative/Procedural report is dictated or electronically entered in the pt record within 24 hrs of the procedure and includes: 1. Patient s name and medical record number; 2. Name and date of procedure; 3. Name of surgeon, proceduralists and assistants; 4. Pre-operative diagnosis, 5. Postoperative diagnosis; 6. Anesthetic agent used; 7. Description of the techniques and procedure; 8. Description of the findings; 9. Estimated blood loss; 10. Specimen(s) removed, if any; 11. Any laboratory or diagnostic procedure ordered; 12. Complications, if any; 13. Condition of patient. RC , 6 & 7 CMS (b) Surgical / procedure Report All elements are in the report and dictated or electronically entered within 24 hours of the procedure. The attending physician has signed the report within 14 days of the procedure. 48 For operative or high-risk procedures and/or the administration of moderate or deep sedation or anesthesia, patients are discharged from recovery area by LIP or by criteria. (Operative/Procedural Areas) PC Discharge Criteria documentation Discharge criteria