Community Hospital Self Assessment

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
Waiting patients are triaged for the most critical need
Staff roles are well defined
Discharged patients receive:
Discharge Instructions
Appropriate prescriptions
Referrals to follow-up physicians or offices
Diagnosis
Reason for discharge
The emergency room has protocols for influx or risk of influx of infectious patients
The emergency department keeps abreast of current information about the emergence of epidemics or new infection risks
Each department supervises infection control practices according to hospital infection control policies
Wait times are monitored, tracked and trended
Staff ratios meet required standards