Resources: Have licensure and policies and procedures available for confirming compliance.
Determinations: The goal is to determine compliance with Risk Management criteria. Examine each question and indicator for strict compliance with regulatory standards and Risk Management standards.
Met, Not Met, Comments: Each item asks if the standard is met, not met and permits comments. Mark each item by examining compliance with standards. Comments refer to the opportunity to improve, departments who need to be notified, corrections or measurements that can impact compliance. Always note if standards are sub-standard and refer the findings to the appropriate department immediately.
Duplication of Standards: Some standards may be duplicates of regulatory standards, or may exceed standards set by regulatory agencies. This tool is designed to examine risks for claims and litigation. Some criteria measures are outside of regulatory agency requirements, and essential to good risk management approaches. Evaluate each standard in regard to claim and litigation risks.
Chart Audits: It is recommended three charts are reviewed for admission compliance; three for discharge compliance; and three current charts with differing diagnoses. It is best practice to review charts for diagnoses that vary to capture the risks for a variety of conditions, staffing care and physician participation.
Personnel: Audit four random nurse personnel records; two therapists; Pharmacist; four nurse assistants; two Radiology employees; two lab employees.
Conduct the Audit: It may be advisable to divide the sections among more than one professional. Be certain to assign audit tools to people who do NOT manage the department they are assigned to audit.
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Community Hospital Self Assessment
