Tracer Record Review - ECT-Periop Only 9-30-2016 Data Definition Tool The Tracer Packet is to be completed in each Periop area 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 is Instructions: Indicate Yes, No, NA (Not Applicable) for each question below. Periop Units: Monitor at least 1 patient record per month using the Tracer Record Review Periop Tool. ADMISSION 1 Medical Record Number: 2 Initial nursing history completed within 24 hours of admission. [those that are admitted as Inpatient] IP = Inpatient OP = Outpatient Standard Location YES No EP 2 & 6 HED: Admission History tab or paper record Admission /History/ Discharge form All components completed & signed by RN w/in timeframe as indicated on (1) Time of Medipac (2) Time order written in CPOE; or (3) Time on Nursing Incompletely filled out, not signed by RN, or > 24 hrs post admit time as indicated on (1) Time of Medipac (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. This update includes an examination and any changes in the patient's condition). EP 4 & 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. Not present or completed within the required timeframes as defined in "Yes" box.
4 Nursing physical assessment completed on admission. PC.01.02.01 EP 1 & 2; EP 6 5 Functional screen complete. PC.01.02.01 EP 1 & 2; 6 If functional screen positive, plans for follow-up PC.01.02.01 EP 1 & 2 7 Nutritional screen complete. PC.01.02.01 EP 1 & 2; ion tab age appropriate 1) 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(IP) VMG Clinic Intake Form (OP) tab (IP); VMG Assesssment & Follow-up for Positive Intake Screen (OP) Admission History/Discharge Plan (IP); VMG Clinic Intake Form (OP) First assessment completed w/in 8 hrs of admit time as indicated on (1) Time of Medipac (2) Time order written in CPOE; or (3) Time on Nursing Functional Screen complete within 24 hours(ip). Activities of Daily Living Section completed (OP) Positive screen & provider contacted, MD notified as free text note (IP), Positive Screen follow-up form (OP) or negative screen = NA Nutritional screen 8 hours (IP) Nutrition Screen completed (OP) Not or > 8 hrs from admit time as indicated on (1) Time of Medipac (2) Time order written in CPOE; or (3) Time on Nursing Admission History Not present or not completed within the required timeframes as defined in "Yes" box. (IP) Functional Screen section incomplete (OP). Positive screen & provider name contacted not (IP) Positive Screen and no follow-up (OP). NA=negative screen or pre-existing condition (i.e., blind, Cerebral Palsy, or ADHD). Nutritional screen incomplete (IP, OP)
8 (OP Only) If nutritional screen positive, plans for follow-pc.01.02.0up EP 1 & 2; 9 Pain screen complete. PC.01.02.07 EP 1 & 2 10 If pain screen positive, plans for follow-up PC.01.02.01 EP 1; PC.01.02.07 EP 3 VMG Assesssment & Follow-up for Postive Intake Screen (OP) tab (IP); VMG Clinic Intake Form (OP) tab (IP); VMG Assesssment & Follow-up for Postive Intake Screen (OP) (OP only) Positive screen follow up form ; or negative screen = NA Pain screen completed within 8 hours (IP) Pain screen completed (OP). Positive screen (score 4) follow up of section of initial screen completed (IP); Positive screen (Option 3 and score >3) follow up form (OP); or negative screen = NA (IP, OP) followup (OP) Pain screen not present or not complete (IP, OP) follow up (IP, OP) 11 Abuse screen complete. PC.01.02.09 EP4 age appropriate tab (IP); VMG Clinic Intake Form (OP) Social Work screen completed (IP); Social Environment screen completed ( OP) Social Work screen incomplete (IP); Social Environment screen incomplete( OP) 12 If abuse screen positive, plans for follow-up PC.01.02.09 EP 6, & 7 13 Falls screen complete. PC.01.02.08 EP 1 age appropriate tab (IP); VMG Assesssment & Follow-up for Postive Intake Screen (OP) VMG Assessment & Follow-up. Positive screen & check in "social work ordered" box (IP); positive screen follow up form (OP); or negative screen = NA (IP, OP) Falls screen completed for pts >/= 65 yrs. (OP) follow up (IP, OP) Falls screen incomplete. (OP)
14 If falls screen positive, plans for follow-up 15 Preferred language for discussing health care PC.01.02.08 EP 2 PC.02.01.21 EP 1 16 Learning needs/education screen complete. PC.02.03.01 EP 1, 4, & 5 VMG Assessment & Follow-up. Admission history; VMG Clinic intake form; and the Star Paneloutpatient white board tab (IP); VMG Clinic Intake Form (OP) Positive screen follow-up form. (OP) Documented Learning needs completed within 8 hours (IP); Educational screen completed (OP) follow up. (OP) Not Learning needs/educational screen incomplete (IP, OP) 17 (OP only) If education screen positive, plans for followup 18 (IP only) Discharge planning initiated within 24 hours of admission. ADVANCE DIRECTIVES (IP Only) 19 Advance Directives Progress Notes (MC#4137) signed and completed. PC.02.03.01 EP 10 PC.04.01.03 EP1 RC.02.01.01 EP 4 RI.01.05.01 EP 9 VMG Assessment & Follow-up Plan of Care Advance Directives Progress Notes and HED Admission / History Extended Data (both completed) Positive screen follow-up form or negative screen = NA Plan initiated w/in timeframe or Case Management & Social Work screen negative Both Advance Directives Progress Notes form and HED data completed to be Yes. follow up Not initiated or initiated > 24 hours post admit time as indicated on (1) Time of Medipac (2) Time order written in CPOE; or (3) Time on Nursing Admission History Form not present or not completed and/or HED data not completed
20 Copy in chart or substance of directive in physician's progress notes or on Advance Directives Progress Notes (MC#4137). PLAN OF CARE (IP Only) 21 Perioperative Services Plan of Care is completed and present in the patient record. RI.01.05.01 EP 9 & 11 PC.01.03.01 EP 1 NURSING ASSESSMENT (IP Only) 22 Physical assessment per shift or unit standard. PC.01.02.01 EP 1; EP 3 23 Patient is reassessed as necessary based on his or her plan for care or changes in his or her condition. 24 Pain assessment at least every shift; when there is a change in patient condition or primary caregiver. EP3 PC.01.02.07 EP 1 25 Interventions r/t pain management are PC.01.02.07 EP 4 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 VPIMS ion age appropriate tab ion age appropriate tab Assessment/ Intervention age appropriate or Pain tab ion age appropriate tab or Pain tab 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 Plan of Care completed Date, nurse signature & title, time and initials are and check mark placed beside "Standards Met" or "Except as Noted" for each section. Date, nurse signature & 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, date, time, initials are Advance Directives Progress Notes form not present or not completed. Plan of Care NOT completed Assessment not present or incomplete Assessment not present or incomplete Time, Date, Pain Score/indicators are NOT or are incomplete. Interventions, date, time, initials are not
26 Pain is reassessed after administration of pain med/comfort measures. PC.01.02.07 EP3 ion age appropriate tab or pain tab and/or Controlled Drug Record Interventions, date time, pain score, and initials are within 2 hrs of intervention. Exception: PCA or continuous infusion IV analgesia assessment every 4 hrs. Interventions, date, time, pain score, and initials are not or are incomplete. PATIENT EDUCATION 27 (IP only) Pain management addressed, as appropriate. 28 All "teaching/education" fields complete, as appropriate (excluding pain management). 29 Documentation by all disciplines involved in the patient's care, treatment or services of patient/family education provided.. PC.02.03.01 EP 10 PC.02.03.01 EP 10 PC.02.03.01 EP 5 Education Record "other" Education Record "other" Same as above. Paper and individual discipline notes 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. All teaching fields specific to pain are not complete All teaching fields are not appropriately completed except pain management teaching. Signature(s) & initials are NOT present for appropriate disciplines. MEDICATION ADMINISTRATION 30 "Do Not Use" Abbreviations are NOT found in the MR on date of service. 31 Supporting documentation (diagnosis, condition, or indication for use) for every order for "current" medications. IM.02.02.01 EP 3 MM.04.01.01 EP 9 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 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 Any "Do Not Use" abbreviations found in the medical record on the date of review. Diagnosis, condition, or indications for use are not in the medical record.
OPERATIVE & OTHER PROCEDURES 32 Consent form present, signed, dated, and timed. RI.01.03.01 EP 13 33 Type of sedation/anesthesia included on consent form. 34 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 includes an update. The update includes an examination and any changes to the patient's condition). RI.01.03.01 EP 13 EP 5 Consent Form Consent form/ Anesthesia Care Record H& P form consent form present signed, dated and timed Type of sedation/anesthesia consent is 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. consent form NOT present or NOT signed, dated or timed Type of sedation/anesthesia consent is not Not present or completed within the required timeframes as defined in "Yes" box. 35 Pre-procedural education before operative or high-risk procedures or before moderate or deep sedation or anesthesia. 36 Patient's condition is re-evaluated before administering moderate or deep sedation. PC.03.01.03 EP 4 PC.03.01.03 EP 8 Sedation & Analgesia Record, Anesthesia record Documented ASA class, Pre- Sedation Status, and focused exam completed for moderate or deep sedation. For OR area: Anesthesia Care Record, ASA score prior to induction completed. Not Moderate/Deep Sedation: ASA class, Pre-Sedation Status, and focused exam not completed. For OR/Anesthesia Cases: ASA score not completed.
37 "Time Out" before procedure. UP.01.03.01 EP 5 38 Immediate Post Operative/procedural Note is present and includes the following: 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; 39 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.02.01.03 EP 7 RC.02.01.03 EP 5, 6 & 7 CMS.482.51.(b) Area Specific documentation systems. Sedation/ Analgesia form. Post surgical progress notes Surgical / procedure Report Completed including Not completed or date and time. date or time missing. All elements are If any element is not 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. 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. Any of these elements are not 40 (Operative/Procedural Areas) For operative or highrisk procedures and/or the administration of moderate or deep sedation or anesthesia, patients are discharged from recovery area by LIP or by criteria. PC.03.01.07 EP 4 Discharge Criteria documentation Discharge criteria discharge criteria not
41 (Outpatient areas) Discharge instructions form present RI.01.01.03 EP 1 Discharge instruction and complete form 42 Patients who receive sedation or anesthesia are discharged in the company of an individual who accepts responsibility for the patient. Wiz or paper Patient Discharge Instructions or discharge letters per specialty Form completed, dated, and timed. Form completed, dated, and timed. Form not completed, dated, or timed. Form completed, dated, and timed.