Convenient Care Clinic Self Assessment

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Convenient Care Clinic
Self Assessment

Instructions	Licensure and Insurance	HIPAA	Employee Training	Care Triage	Risk Management
Quality Improvement	Environment of Care	Infection Control	Patient Management	Documentation	Pharmaceutical Management

CRITERIA MEASURE	Met	Not Met	Comments	Refer to Department
Patient History and Physical is on the record before admission and includes at least:
Drug Allergies
Current OTC medications
Current Prescription Medications
Suspected cause of the current complaint
If the problem is new or recurring
Most recent medical treatment received
Drug and Alcohol use
Communicable diseases (HIV, Hepatitis, etc.)
Prior surgeries
Weight
Age
Infection Control practices in place for visitors
Blood and other specimen containers are labeled in the presence of the patient or patient's family
Reasons for tests are not communicated to unauthorized persons
Phone orders and phone test results are "read back" to confirm accuracy
The orders are written in the patient's chart at the time of the phone contact
Standardized acceptable abbreviations, acronyms, symbols and dose designations are readily available to staff
Staff is educated to sound-a-like and look-a-like drugs. A list is kept at each nursing station.
The clinic has a standardized of unacceptable abbreviations, acronyms, symbols and dose designations available to staff.
Charting is completed prior the end of each shift
Time allowance for entry of test criteria is clearly defined and enforced
All medications are labeled
Drug name
Patients Name
Expiration Date
Strength
Amount
Route
Dose
Medication administration is triple checked for order, patient, dose, route and counter indications
All unused medication open in the sterile field are discarded
Staff know when and how to ask for specialized assistance
Patients are educated regarding their care upon discharge
Patients are informed regarding charges for care provided
Patients are not refused care due to inability to pay
Patient's religious, cultural and ethnic differences are respected
Urgent response system is effective and implemented on all units
Patients are informed regarding staff and physician names
Pain is assessed regularly and clearly documented
Patients are assessed for needs including:
Medical history
Current medical condition
Psychological condition
Social condition
Nutritional and hydration
Functional status
Cultural variances
Nutritional screening is completed within 24 hours of admission
Discharged patients receive:
Discharge Instructions
Appropriate prescriptions
Referrals to follow-up physicians or offices
Diagnosis