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
Information is captured and shared with privacy and confidentiality
Nurses document every shift
History and Physical is filed in the patient's chart
Lab reports are filed timely
Physician orders are filed upon admission to the unit
Pharmacy orders are filled within 1 hour of admission
Closed patient files are retained for at least 7 years
Closed patients files are stored in a moisture proof storage area, free from pests and rodents
Phone orders are accepted by authorized trained staff
Phone orders are noted by authorized trained staff
Active patients records are accessible to authorized staff
Each record contains a sheet identifying signatures, names and titles
Signatures are identifiable according to the signature sheet
Passwords for electronic medical records are changed every 90 days
Policies exist to delineate electronic signatures
Documentation includes:
Diagnosis
Course of Care
Justification for treatment
Results of Care
Continuity of Care
Documentation is:
Legible
Timely
Observational in nature
Free from opinion
Secure
The record includes:
Patient demographic information
Patient's legal status: minor or adult
Emergency care provided prior to admission
Relevant observations
Findings of assessments
Conclusions from medical history
Diagnoses
Reason for admission
Goals for treatment
Advance Directives inclusion or refusal
Informed consent
Diagnostic test orders
Diagnostic test results
Operative procedures
Progress notes per shift or patient contact
Clinical observations
Patient's response to care
Consultation reports
All medications ordered
Medications dispensed on discharge
All medications administered
All drug reactions
All referrals
Discharge summary describing course of care
Suspicions of abuse, neglect or criminal act
A treatment plan or care plan is initiated within 24 hours of admission
Documentation supports the Treatment Plan or Care Plan
Effects of medications are monitored and documented:
PRN medications for pain
Adverse reactions
Side effects
First dose reactions
The hospital's medication management system is evaluated at least annually for:
Risks for errors
System improvements
Review of new technologies
Safe practices and protocols