Community Hospital Self Assessment

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Community Hospital
Self Assessment

Instructions	Licensure and Insurance	HIPAA	Employee Training	Lab	Anesthesia	Emergency Room	Risk Management
Quality Improvement	Environment of Care	Restraint Use	Infection Control	Falls Management	Patient Management	Documentation	Pharmaceutical Management

CRITERIA MEASURE	Met	Not Met	Comments	Refer to Department
Staffing is sufficient to provide and monitor anesthesia administration
RN supervises perioperative nursing care
Appropriate equipment is monitored during sedation
Preventive maintenance is current for all sedation equipment
Resuscitation equipment is available at all times during sedation
Appropriate IV equipment to deliver anesthesia and drugs is available
Patient's needs are assessed and equipment is secured prior to the initiation of the procedure
Plan of care reflects treatments prior to initiation of the procedure
Proper triple patient identification is completed prior to the procedure
Time-out procedures are implemented and followed prior to the initiation of the procedure includes at least:
Patient identity
The procedure to be performed
Side and site
Patient position
Necessary implants when required (e.g. hip and joint)
Presedation or preanesthesia assessment is performed on every patient
LIP consults concur with the planned sedation
Patients are monitored and documentation provided includes:
Oxygenation
Ventilation
Circulation
Recovery is monitored and documented:
Physiological status
Mental status
Pain Level
Nausea and vomiting
Temperature
Urine output
Bleeding
Discharge from Recovery is dictated by written criteria and documented in the patient's record
Preanesthesia visits are conducted for each patient 48 hours prior to surgery
Time based log accurately reflects procedures
Clinicians adhere to the American Society of Anesthesiologists standards for monitoring