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 compliance; three for discharge instructions compliance; and three with referral 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 personnel records.
Conduct the Audit: It may be advisable to divide the sections among more than one professional.
_________________________________________________
Click on the icon above to download the
Convenient Care Clinic Self Assessment
