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Medical Records Procedure Audit Data Definition Tool 1 2 3 4 5 This audit is to be completed by the manager or designee on a monthly basis. "Medical Records Procedure Audit" audits are due by the last day of the month. Instructions: Indicate Yes, No, NA (Not Applicable) for each question below. Submit 1 "Medical Records Procedure Audit" audit per month using the "Medical Records Procedure Audit" audit tool. Updated: 6-5-15 QUESTION STANDARD LOCATION YES Which hospital is the medical from (VUH, VCH, or VPH) Was the patient inpatient or same day surgery medical record number Medical Record Audit Pre Procedure operation/procedure date Is the history and physical documented prior to the procedure? RC 02.01.03 EP3 H&P H&P is completed or updated after admission or registration and prior to procedure starting. (may use H&P documented w/in 30 prior to admission with updated examination and any change's to patient condition) 6 Consent form is present and signed prior to operation/procedure. RC.02.01.01 EP4 Consent form 7 Provisional diagnosis is recorded prior to procedure by LIP involved in patient's care. Medical Record Audit Operative/Procedural Report RC.02.01.03 EP2 H&P form is completed and in patient's chart H&P NA there is documentation that the patient required lifesaving surgery before H&P could be done 8 Operative/Procedure report is written or dictated upon completion of the operative/procedure and before the patient is transferred to the next level of care. RC.02.01.03 EP5 Operative/ Procedure Operative/Procedure Report is Report completed and in patient's chart prior to leaving the operating room OR Brief/Immediate Post Op Note is completed prior to leaving operating room or within 15 mins. of procedure stop time RC.02.01.03 EP5 Operative/ Procedure Operative/Procedure Report is Report entered or dictated within 24 hours of the operative/procedure completion exception to this requirement: progress note (Brief/ Immediate Post Op Note) is completed immediately after the procedure 9 Operative/Procedural report is entered or dictated within 24 hours of the Operative/Procedure completion. 10 Does the report contain the names of the surgeon(S), proceduralist(S), RC.02.01.03 EP6 and/or assistant(S)? Operative/ Procedure documented Report 11 Is the post procedure diagnosis present? RC.02.01.03 EP6 12 Does the report include the description of the procedure and techniques used? 13 Is the estimated blood loss listed? RC.02.01.03 EP6 14 Does the report include specimen(s) removed if any? RC.02.01.03 EP6 15 Are the findings of the procedure (s) present? RC.02.01.03 EP6 16 Is the name of the procedure(s) present? RC.02.01.03 EP6 Operative/ Procedure Report Operative/ Procedure Report Operative/ Procedure Report Operative/ Procedure Report Operative/ Procedure Report Operative/ Procedure Report RC.02.01.03 EP6 Operative/Procedure Report is completed prior to patient leaving operating room documented narrative of operative report documented documented narrative of operative report documented procedure had no specimens 17 The operative/procedure report includes: - The name(s) of the licensed independent practitioner(s) who performed the procedure and his or her assistant(s) - The name of the procedure performed - A description of the procedure - Findings of the procedure - Any estimated blood loss - Any specimen(s) removed - The postoperative diagnosis Medical Record Audit Brief/Immediate Procedure Note 18 Was the brief/immediate note entered immediately after the procedure (before patient is transferred to next level of care)? RC.02.01.03 EP6 Operative/ Procedure all elements are documented Report RC.02.01.03 EP7 Brief/Immediate Post Brief/Immediate Post Op Note is Op Note completed and in patient's chart prior to leaving the operating room OR Brief/Immediate Post Op Note is completed within 15 mins. of procedure stop time 19 Is the post operative diagnosis listed? RC.02.01.03 EP7 20 Does the immediate/brief note contain the procedure(s) preformed? RC.02.01.03 EP7 21 RC.02.01.03 EP7 Brief/Immediate Post Op Note Brief/Immediate Post Op Note Brief/Immediate Post Op Note Brief/Immediate Post Op Note Brief/Immediate Post Op Note Brief/Immediate Post Op Note Is the name of the surgeon(S)/assistant(S) listed? 22 RC.02.01.03 EP7 Are the findings of the procedure stated? 23 RC.02.01.03 EP7 Is the estimated blood loss give? 24 Does the procedure note contain if a specimen was or was not removed? RC.02.01.03 EP7 documented documented documented documented documented documented Operative/Procedure Report is completed and in patient's chart prior to leaving the operating room leaving the operating room 25 RC.02.01.03 EP7 When a full operative/procedure report cannot be entered immediately into the patient’s medical record after the operation/procedure, a progress note is entered in the medical record before the patient is transferred to the next level of care. This progress note includes - the name(s) of the primary surgeon(s) and his or her assistant(s), - procedure performed and a description of each procedure finding, - estimated blood loss, - specimens removed, - postoperative diagnosis Medical Records Post Procedure 26 The medical record contains the following postoperative information: RC.02.01.03 EP8 - The patient’s vital signs and level of consciousness - Any medications, including intravenous fluids and any administered blood, blood products, and blood components - Any unanticipated events or complications (including blood transfusion reactions) and the management of those events **If patient does not go to recovery room and is taken to floor there will be no Post Anesthesia Record. Information needed will be in progress notes, inpatient vital signs, and MAR. Brief/Immediate Post all elements are documented Op Note Post anesthesia Record document present in chart 27 Was the patient discharged from post sedation by a licensed independent practitioner? RC.02.01.03 EP9 Post Anesthesia Record and/or PACU orders document present in chart patient does not go to recovery room and is taken to the floor 28 Was there documentation of the approved discharge criteria that determine the patient's readiness for discharge? RC.02.01.03 EP10 PACU orders document present in chart 29 Does the postoperative documentation contain the name of the licensed independent practitioner responsible for discharge? RC.02.01.03 EP11 Post Anesthesia Record and/or PACU orders document present in chart patient does not go to recovery room and is taken to the floor patient does not go to recovery room and is taken to the floor 30 The hospital has a complete and up-to-date operating room register that includes the following: - Patient's name - Patient's hospital identification number - Date of operation - Inclusive or total time of operation - Name of surgeon and any assistants - Name of nursing personnel - Type of anesthesia used and name of person administering it - Operation performed - Pre and postoperative diagnosis - Age of patient ***postoperative summary may be considered equivalent if all items listed RC.02.01.03 EP15 OR Nursing Record document present in chart
