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.