Download Tracer Record Review - ECT-Periop Only 3-11-2016

Tracer Record Review - ECT-Periop Only 3-11-2016
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.
Standard
Location
IP = Inpatient
OP = Outpatient
YES
No
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]
PC.01.02.03
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
transaction to admit;
(2) Time order
written in CPOE; or
(3) Time on Nursing
Admission History
Incompletely filled
out, not signed by
RN, or > 24 hrs post
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
3 Provider history and physical (H&P) completed and
documented.
PC.01.02.03
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
documented 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.
(May use previous H&P documented 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).
4 Nursing physical assessment completed on
admission.
PC.01.02.01
EP 4;
PC.01.02.03
EP 6
5 Functional screen complete.
PC.01.02.01
EP 4;
PC.01.02.03
EP 8
6 If functional screen positive, plans for follow-up
documented.
PC.01.02.01
EP4
7 Nutritional screen complete.
PC.01.02.01
EP 4;
PC.01.02.03
EP 7
Assessment/Intervent First assessment
completed w/in 8 hrs
ion tab age
of admit time as
appropriate
indicated on (1)
Time of Medipac
transaction to admit;
(2) Time order
written in CPOE; or
(3) Time on Nursing
Admission History
1) Admission History Functional Screen
StarForm in
complete within 24
StarPanel for units
hours(IP).
that chart in HED
Activities of Daily
(nurseries do not
Living Section
complete Functional completed (OP)
Screen on
newborns); 2) paper
admission history if
completed in area
that does not
document in HED(IP)
VMG Clinic Intake
Form (OP)
Admission History
tab (IP); VMG
Assesssment &
Follow-up for Positive
Intake Screen (OP)
Positive screen &
provider contacted,
MD notified
documented as free
text note (IP),
Positive Screen
follow-up
documented on
form (OP) or
negative screen =
NA
Not documented or >
8 hrs from 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
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
documented. (IP)
Positive Screen and
no documentation of
follow-up (OP).
NA=negative screen
or pre-existing
condition (i.e., blind,
Cerebral Palsy, or
ADHD).
Admission
Nutritional screen 8 Nutritional screen
History/Discharge
hours (IP)
incomplete (IP, OP)
Plan (IP); VMG Clinic Nutrition Screen
completed (OP)
Intake Form (OP)
8 (OP Only) If nutritional screen positive, plans for follow- PC.01.02.01
up documented.
EP 4;
PC.01.02.03
EP 7
VMG Assesssment & (OP only) Positive
Follow-up for Postive screen follow up
Intake Screen (OP) documented on
form ; or negative
screen = NA
Admission History
Pain screen
tab (IP); VMG Clinic completed within 8
hours (IP)
Intake Form (OP)
Pain screen
completed (OP).
Admission History
Positive screen
(score ≥4) follow up
tab (IP); VMG
of section of initial
Assesssment &
Follow-up for Postive screen completed
Intake Screen (OP) (IP); Positive screen
(Option 3 and score
>3) follow up
documented on
form (OP); or
negative screen =
NA (IP, OP)
Positive screen & no
documentation of
followup (OP)
9 Pain screen complete.
PC.01.02.07
EP 1 & 2
Pain screen not
present or not
complete (IP, OP)
10 If pain screen positive, plans for follow-up
documented.
PC.01.02.01
EP 23;
PC.01.02.07
EP 3
11 Abuse screen complete.
PC.01.02.09
EP4
Admission History
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
documented.
PC.01.02.09
EP 5, 6, & 7
Admission History
age appropriate tab
(IP); VMG
Assesssment &
Follow-up for Postive
Intake Screen (OP)
Positive screen & no
documentation of
follow up (IP, OP)
13 Falls screen complete.
PC.01.02.08
EP 1
VMG Assessment &
Follow-up.
Positive screen &
check in "social
work ordered" box
(IP); positive screen
follow up
documented on
form (OP); or
negative screen =
NA (IP, OP)
Falls screen
completed for pts
>/= 65 yrs. (OP)
Positive screen & no
documentation of
follow up (IP, OP)
Falls screen
incomplete. (OP)
14 If falls screen positive, plans for follow-up
documented.
PC.01.02.08
EP 2
VMG Assessment &
Follow-up.
15 Preferred language for discussing health care
documented.
PC.02.01.21
EP 1
Not documented.
16 Learning needs/education screen complete.
PC.02.03.01
EP 1, 4, & 5
Admission history;
VMG Clinic intake
form; and the Star
Paneloutpatient white
board
Admission History
Learning needs
tab (IP); VMG Clinic completed within 8
hours (IP);
Intake Form (OP)
Educational screen
completed (OP)
VMG Assessment & Positive screen
follow-up
Follow-up
documented on
form or negative
screen = NA
Plan of Care
Plan initiated w/in
timeframe or Case
Management &
Social Work screen
negative
Positive screen & no
documentation of
follow up
Advance Directives
Progress Notes and
HED Admission /
History Extended
Data (both
completed)
Form not present or
not completed and/or
HED data not
completed
17 (OP only) If education screen positive, plans for follow- PC.02.03.01
up documented.
EP 10
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.04.01.03
EP1
RC.02.01.01
EP 4
RI.01.05.01
EP 9
Positive screen
follow-up
documented on
form. (OP)
Documented
Both Advance
Directives Progress
Notes form and
HED data
completed to be
Yes.
Positive screen & no
documentation of
follow up. (OP)
Learning
needs/Educational
screen incomplete
(IP, OP)
Not initiated or
initiated > 24 hours
post 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
20 Copy in chart or substance of directive in physician's
progress notes or on Advance Directives Progress
Notes (MC#4137).
RI.01.05.01
EP 9 & 11
PLAN OF CARE (IP Only)
21 Perioperative Services Plan of Care is completed and PC.01.03.01
present in the patient record.
EP 1
NURSING ASSESSMENT (IP Only)
22 Physical assessment per shift or unit standard.
PC.01.02.01
EP 23;
PC.01.02.03
EP 3
23 Patient is reassessed as necessary based on his or
her plan for care or changes in his or her condition.
PC.01.02.03
EP3
24 Pain assessment at least every shift; when there is a
change in patient condition or primary caregiver.
PC.01.02.07
EP 1
25 Interventions r/t pain management are documented.
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
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
Advance Directives
Progress Notes form
not present or not
completed.
VPIMS
Plan of Care
completed
Plan of Care NOT
completed
Assessment/Intervent Date, nurse
ion age appropriate signature & title,
time and initials are
tab
documented and
check mark placed
beside "Standards
Met" or "Except as
Noted" for each
section.
Assessment/Intervent Date, nurse
ion age appropriate signature & title,
time and initials are
tab
documented and
check mark placed
beside "Standards
Met" or "Except as
Noted" for each
section.
Assessment/
Time, Date, Pain
Intervention age
Score/indicators are
appropriate or Pain documented
tab
Assessment/Intervent Interventions, date,
ion age appropriate time, initials are
documented.
tab or Pain tab
Assessment not
present or incomplete
Assessment not
present or incomplete
Time, Date, Pain
Score/indicators are
NOT documented or
are incomplete.
Interventions, date,
time, initials are not
documented.
26 Pain is reassessed after administration of pain
med/comfort measures.
PC.01.02.07
EP3
Assessment/Intervent
ion age appropriate
tab or pain tab and/or
Controlled Drug
Record
PATIENT EDUCATION
27 (IP only) Pain management addressed, as
appropriate.
PC.02.03.01
EP 10
Education Record
"other"
28 All "teaching/education" fields complete, as
appropriate (excluding pain management).
PC.02.03.01
EP 10
29 Documentation by all disciplines involved in the
patient's care, treatment, or services.
PC.02.03.01
EP 5
MEDICATION ADMINISTRATION
30 "Do Not Use" Abbreviations are NOT found in the MR IM.02.02.01
on date of service.
EP 3
31 Supporting documentation (diagnosis, condition, or
indication for use) for every order for "current"
medications.
MM.04.01.01
EP 9
Interventions, date
time, pain score,
and initials are
documented within 2
hrs of intervention.
Exception: PCA or
continuous infusion
IV analgesia
assessment
documented every 4
hrs.
Interventions, date,
time, pain score, and
initials are not
documented or are
incomplete.
All teaching fields
specific to pain are
completed.
Education Record
All teaching fields
"other"
are appropriately
completed except
pain management
teaching.
Same as above.
Signature(s) &
Paper and individual initials are present
discipline notes
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.
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.
Any "Do Not Use"
abbreviations found
in the medical record
on the date of review.
Diagnosis, condition
or indications for
use are documented
anywhere in the
medical record
including the H&P
Diagnosis, condition,
or indications for use
are not documented
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.
RI.01.03.01
EP 13
34 Provider history and physical (H&P) completed and
documented prior to procedure.
PC.01.02.03
EP 5
(May use previous H&P documented 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).
35 Pre-procedural education documented 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
Consent Form
Consent form/
Anesthesia Care
Record
H& P form
consent form
present signed,
dated and timed
Type of
sedation/anesthesia
consent is
documented
H&P time on record
w/in appropriate
timeframes which
are up to 24 hrs
including:
Previous H&P
documented 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.
Documented
Sedation & Analgesia ASA class, PreRecord, Anesthesia Sedation Status,
record
and focused exam
completed for
moderate or deep
sedation.
For OR area:
Anesthesia Care
Record, ASA score
prior to induction
completed.
consent form NOT
present or NOT
signed, dated or
timed
Type of
sedation/anesthesia
consent is not
documented
Not present or
completed within the
required timeframes
as defined in "Yes"
box.
Not documented.
Moderate/Deep
Sedation: ASA class,
Pre-Sedation Status,
and focused exam
not completed.
For OR/Anesthesia
Cases: ASA score
not completed.
37 "Time Out" documented before procedure.
UP.01.03.01
EP 5
38 Immediate Post Operative/procedural Note is present RC.02.01.03
EP 7
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 5, 6 & 7
Area Specific
documentation
systems. Sedation/
Analgesia form.
Post surgical
progress notes
Surgical / procedure
Report
CMS.482.51.(b)
40 (Operative/Procedural Areas) For operative or highPC.03.01.07
risk procedures and/or the administration of moderate EP 4
or deep sedation or anesthesia, patients are
discharged from recovery area by LIP or by criteria.
Discharge Criteria
documentation
Completed including
date and time.
All elements are
documented 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
documented 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.
Not completed or
date or time missing.
If any element is not
documented.
Discharge criteria
documented
discharge criteria not
documented
Any of these
elements are not
documented.
41 (Outpatient areas) Discharge instructions form present
and complete
42 Patients who receive sedation or anesthesia are
discharged in the company of an individual who
accepts responsibility for the patient.
PC.04.01.05
EP 8
PC.03.01.07
EP 6
Discharge instruction
form
Wiz or paper Patient
Discharge
Instructions or
discharge letters per
specialty
Form completed,
dated, and timed.
Form not completed,
dated, or timed.
Form completed,
dated, and timed.
Form completed,
dated, and timed.