Upcoming Joint Commission Survey: Readiness Tips for Physicians
BWH's survey window is open through Feb. 5, 2013, meaning that The Joint Commission surveyors will show up unannounced sometime between now and then for the hospital accreditation survey.
Key topics that surveyors are likely to include during their patient tracers are infection control, the National Patient Safety Goals, restraints, interdisciplinary care and continuity, and hand-off communication.
Documentation is an especially important area of focus for medical staff. Brush up on the following reminders about accurate and complete documentation:
- All entries in the medical record must be dated, timed, signed and legible.
- Do not use any abbreviations, acronyms or symbols that are on the "Do Not Use" list.
- Complete history and physical examinations within 24 hours of admission and prior to surgery.
- Update the patient condition just prior to anesthesia induction via the Day of Procedure Re-Assessment/Brief Op Note form.
- Brief operative and procedural notes -
- Ensure that informed consents are complete.
- Update progress notes daily.
- Ensure there are no inconsistencies with allergy information between disciplines.
- In the outpatient setting, advance directives must be asked of all new patients, emergency room patients, observation patients, surgical day care and annually for primary care patients. Advance directives must be asked of inpatients upon admission by Patient Access staff and documented on the nursing assessment form and electronically. A copy of the health care proxy form is placed in the medical record, and the physician should review this with the patient.
For more information about survey readiness, visit the Compliance section on BWHPikeNotes.org.