| CRITERIA MEASURE |
Met |
Not Met |
Comments |
Refer to Department |
 Information is captured and shared with privacy and confidentiality |
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| History and Physical is filed in the patient's chart |
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| Lab reports are filed timely |
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| Physician orders are filed |
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| Closed patient files are retained for at least 7 years |
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| Closed patients files are stored in a moisture proof storage area, free from pests and rodents |
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| Phone orders are accepted by authorized trained staff |
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| Phone orders are noted by authorized trained staff |
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| Active patients records are accessible to authorized staff |
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| Each record contains a sheet identifying signatures, names and titles |
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| Signatures are identifiable according to the signature sheet |
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| Passwords for electronic medical records are changed every 90 days |
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| Policies exist to delineate electronic signatures |
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| Documentation includes: |
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| Diagnosis |
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| Course of Care |
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| Justification for treatment |
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| Results of Care |
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| Continuity of Care |
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| Documentation is: |
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| Legible |
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| Timely |
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| Observational in nature |
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| Free from opinion |
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| Secure |
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| The record includes: |
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| Patient demographic information |
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| Patient's legal status: minor or adult |
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| Care provided |
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| Relevant observations |
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| Findings of assessments |
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| Conclusions from medical history |
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| Diagnoses |
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| Goals for treatment |
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| Informed consent |
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| Diagnostic test orders |
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| Diagnostic test results |
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| Progress notes per shift or patient contact |
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| Clinical observations |
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| Patient's response to care |
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| Consultation reports |
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| All medications ordered |
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| Medications dispensed on discharge |
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| All medications administered |
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| All drug reactions |
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| All referrals |
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| Discharge summary describing course of care |
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| Suspicions of abuse, neglect or criminal act |
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| A treatment plan or care plan is provided to the patient |
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| Documentation supports the Treatment Plan or Care Plan |
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| Effects of medications are monitored and documented: |
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| Adverse reactions |
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| Side effects |
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| First dose reactions |
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| The hospital's medication management system is evaluated at least annually for: |
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| Risks for errors |
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| System improvements |
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| Review of new technologies |
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| Safe practices and protocols |
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Copyright © OmniSure Consulting Group, Inc., 2008
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