Demographics

Date of admission:
Date of discharge:

Medical Record or Encounter Number:

AGE:

Gender

Attending:

Consultant 1:

Consultant 2:

Consultant 3:

Admitting Dx:

Race and Ethnicity are documented (RC.02.01.01 EP28)

The medical record contains the following demographic information (RC.02.01.01 EP1):

Did the patient receive emergent or urgent care prior to admission?

The time and means of arrival are documented (RC.02.01.01 EP21)

Indication that the patient left against medical advice, when applicable(RC.02.01.01 EP21)

Conclusions reached at the termination of care, treatment, and services, including the patient's final disposition, condition, and instructions given for follow-up care, treatment, and services (RC.02.01.01 EP21)

A copy of any information made available to the practitioner or medical organization providing follow-up care, treatment, or services (RC.02.01.01 EP21)

Copy of rights prior to provision of care, treatment and services (RI.01.01.01 EP2)

Consent to treatment.

Rights and Responsibilities

The hospital respects, protects, and promotes patients' rights.

The hospital informs the patient of his or her rights. (RI.01.01.01 EP2)
Note 1: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital informs
the patient (or support person, where appropriate) of his or her visitation rights. Visitation rights include the
right to receive the visitors designated by the patient, including, but not limited to, a spouse, a domestic partner
(including a same-sex domestic partner), another family member, or a friend. Also included is the right to
withdraw or deny such consent at any time.
Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital makes
sure that each patient, or his or her family, is informed of the patient’s rights in advance of furnishing or
discontinuing patient care whenever possible.

The hospital provides language interpreting and translation services. (See also HR.01.01.01, EP 1; PC.02.01.21,
EP 2; RI.01.01.01, EPs 2 and 5)
Note: Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These options may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population. (RI.01.01.03 EP2)

The hospital provides the patient or surrogate decision-maker with written information about the right to refuse care, treatment, and services. (RI.01.02.01 EP3)

The informed consent process includes a discussion about the following:
- The patient's proposed care, treatment, and services.
- Potential benefits, risks, and side effects of the patient's proposed care, treatment, and services; the likelihood of the patient achieving his or her goals; and any potential problems that might occur during recuperation.
- Reasonable alternatives to the patient's proposed care, treatment, and services. The discussion encompasses risks, benefits, and side effects related to the alternatives and the risks related to not receiving the proposed care, treatment, and services. (RI.01.03.01 EP2)

The hospital obtains and documents informed consent in advance when it makes and uses recordings, films, or
other images of patients for internal use other than the identification, diagnosis, or treatment of the patient (for
example, performance improvement and education).(RI.01.03.01 EP3)
Note 1: The term "recordings, films, or other images" refers to photographic, video, digital, electronic, or audio
media.
Note 2: This element of performance does not apply to the use of security cameras.

The hospital documents the following in the research consent form:
- That the patient received information to help determine whether or not to participate in the research, investigation, or clinical trials
- That the patient was informed that refusing to participate in research, investigation, or clinical trials or discontinuing participation at any time will not jeopardize his or her access to care, treatment, and services unrelated to the research
- The name of the person who provided the information and the date the form was signed
- The patient's right to privacy, confidentiality, and safety (RI.01.03.5 EP4)

The hospital documents whether or not the patient has an advance directive. (RI.01.05.01 EP9)

When required by policy or upon patient request, the hospital documents the patient’s wishes concerning organ donation and honors the wishes within the limits of its capability, policy, and law and regulation.(RI.01.05.01 EP15)

Provision of Care

PC.01.02.03: The hospital assesses and reassesses the patient and his or her condition according to defined time frames.

EP2 The hospital performs initial patient assessments within its defined time frame.

EP3 Each patient is reassessed as necessary based on his or her plan for care or changes in his or her condition. Note: Reassessments may also be based on the patient's diagnosis; desire for care, treatment, and services; response to previous care, treatment, and services; discharge planning needs; and/or his or her setting requirements.

EP4 The patient receives a medical history and physical examination no more than 30 days prior to, or within 24 hours after, registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services.

EP5 For a medical history and physical examination that was completed within 30 days prior to registration or inpatient admission, an update documenting any changes in the patient's condition is completed within 24 hours after registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services.

EP6 A registered nurse completes a nursing assessment within 24 hours after the patient’s inpatient admission.

PC.01.02.07: The hospital assesses and manages the patient’s pain and minimizes the risks associated with treatment.

EP1 The hospital has defined criteria to screen, assess, and reassess pain that are consistent with the patient’s age, condition, and ability to understand.

EP2 The hospital screens patients for pain during emergency department visits and at the time of admission.

EP4 The hospital develops a pain treatment plan based on evidence-based practices and the patient’s clinical condition, past medical history, and pain management goals.

EP5 The hospital involves patients in the pain management treatment planning process through the following: - Developing realistic expectations and measurable goals that are understood by the patient for the degree, duration, and reduction of pain - Discussing the objectives used to evaluate treatment progress (for example, relief of pain and improved physical and psychosocial function) - Providing education on pain management, treatment options, and safe use of opioid and non-opioid medications when prescribed

EP6 The hospital monitors patients identified as being high risk for adverse outcomes related to opioid treatment.

EP7 The hospital reassesses and responds to the patient’s pain through the following: - Evaluation and documentation of response(s) to pain intervention(s) (See also RC.01.01.01, EP 7) - Progress toward pain management goals including functional ability (for example, ability to take a deep breath, turn in bed, walk with improved pain control) - Side effects of treatment - Risk factors for adverse events caused by the treatment

EP8 The hospital educates the patient and family on discharge plans related to pain management including the following: - Pain management plan of care - Side effects of pain management treatment - Activities of daily living, including the home environment, that might exacerbate pain or reduce effectiveness of the pain management plan of care, as well as strategies to address these issues - Safe use, storage, and disposal of opioids when prescribed

PC.01.02.08: The hospital assesses and manages the patient's risks for falls.

EP1 The hospital assesses the patient’s risk for falls based on the patient population and setting.

PC.01.02.09: The hospital assesses the patient who may be a victim of possible abuse and neglect.

EP4 The hospital uses its criteria to identify possible victims of abuse and neglect upon entry into the hospital and on an ongoing basis.

PC.01.03.01: The hospital plans the patient’s care.

EP5 The written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals. Note: For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The patient’s goals include both short- and long-term goals.

EP22 Based on the goals established in the patient’s plan of care, staff evaluate the patient’s progress.

EP23 The hospital revises plans and goals for care, treatment, and services based on the patient’s needs. (See also RC.02.01.01, EP 2)

PC.02.01.01: The hospital provides care, treatment, and services for each patient.

EP15 For hospitals that use Joint Commission accreditation for deemed status purposes: Blood transfusions and intravenous medications are administered in accordance with state law and approved medical staff policies and procedures.

PC.02.01.03: The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.

EP1 For hospitals that use Joint Commission accreditation for deemed status purposes: Prior to providing care,

treatment, and services, the hospital obtains or renews orders (verbal or written) from a licensed independent

practitioner or other practitioner in accordance with professional standards of practice; law and regulation;

hospital policies; and medical staff bylaws, rules, and regulations. *

Note 1: Outpatient services may be ordered by a practitioner not appointed to the medical staff as long as he or she meets the following: - Responsible for the care of the patient - Licensed to practice in the state where he or she provides care to the patient or in accordance with Veterans and Department of Defense licensure requirements - Acting within his or her scope of practice under state law - Authorized in accordance with state law and policies adopted by the medical staff and approved by the governing body to order the applicable outpatient services Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: Patient diets, including therapeutic diets, are ordered by the practitioner responsible for the patient’s care, or by a qualified dietitian or qualified nutrition professional who is authorized by the medical staff and acting in accordance with state law governing dietitians and nutrition professionals.

Ep20 Before taking action on a verbal order or verbal report of a critical test result, staff uses a record and "read back" process to verify the information.

PC.02.01.21: The hospital effectively communicates with patients when providing care, treatment, and services.

EP1 The hospital identifies the patient's oral and written communication needs, including the patient's preferred language for discussing health care. (See also RC.02.01.01, EP 1) Note: Examples of communication needs include the need for personal devices such as hearing aids or glasses, language interpreters, communication boards, and translated or plain language materials.

EP2 The hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient's oral and written communication needs.

PC.02.03.01: The hospital provides patient education and training based on each patient’s needs and abilities.

EP1 The hospital performs a learning needs assessment for each patient, which includes the patient’s cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication.

EP10 Based on the patient’s condition and assessed needs, the education and training provided to the patient by the hospital include any of the following:

- An explanation of the plan for care, treatment, and services

- Basic health practices and safety

Information on the safe and effective use of medications

Nutrition interventions (for example, supplements) and modified diets

Discussion of pain, the risk for pain, the importance of effective pain management, the pain assessment process, and methods for pain management

Information on oral health

Information on the safe and effective use of medical equipment or supplies provided by the hospital

Habilitation or rehabilitation techniques to help the patient reach maximum independence

Fall reduction strategies

EP25 The hospital evaluates the patient’s understanding of the education and training it provided.

EP27 The hospital provides the patient education on how to communicate concerns about patient safety issues that occur before, during, and after care is received.

PC.03.01.03: The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.

EP1 Before operative or other high-risk procedures are initiated, or before moderate or deep sedation or anesthesia is administered: The hospital conducts a presedation or preanesthesia patient assessment.

EP4 Before operative or other high-risk procedures are initiated, or before moderate or deep sedation or anesthesia is administered: The hospital provides the patient with preprocedural education, according to his or her plan for care.

EP8 The hospital reevaluates the patient immediately before administering moderate or deep sedation or anesthesia.

18 For hospitals that use Joint Commission accreditation for deemed status purposes: A preanesthesia evaluation is completed and documented by an individual qualified to administer anesthesia within 48 hours prior to surgery or a procedure requiring anesthesia services.

PC.03.01.07: The hospital provides care to the patient after operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia.

EP1 The hospital assesses the patient’s physiological status immediately after the operative or other high risk procedure and/or as the patient recovers from moderate or deep sedation or anesthesia.

EP4 A qualified licensed independent practitioner discharges the patient from the recovery area or from the hospital. In the absence of a qualified licensed independent practitioner, patients are discharged according to criteria approved by clinical leaders.

EP7 For hospitals that use Joint Commission accreditation for deemed status purposes: A postanesthesia evaluation is completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services.

PC.03.05.01: The hospital uses restraint or seclusion only when it can be clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others.

EP3 The hospital uses restraint or seclusion only when less restrictive interventions are ineffective.

EP4 The hospital uses the least restrictive form of restraint or seclusion that protects the physical safety of the patient, staff, or others.

EP5 The hospital discontinues restraint or seclusion at the earliest possible time, regardless of the scheduled expiration of the order.

PC.03.05.03: The hospital uses restraint or seclusion safely.

EP2 The use of restraint and seclusion is in accordance with a written modification to the patient's plan of care.

PC.03.05.05: The hospital initiates restraint or seclusion based on an individual order.

EP1 A physician, clinical psychologist, or other authorized licensed independent practitioner primarily responsible for the patient’s ongoing care orders the use of restraint or seclusion in accordance with hospital policy and law and regulation.

EP3 The attending physician or clinical psychologist is consulted as soon as possible, in accordance with hospital policy, if he or she did not order the restraint or seclusion.

EP4 Unless state law is more restrictive, orders for the use of restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others may be renewed within the following limits:
(Orders may be renewed according to the time limits for a maximum of 24 consecutive hours.)

- 4 hours for adults 18 years of age or older

- 2 hours for children and adolescents 9 to 17 years of age

- 1 hour for children under 9 years of age

EP5 Unless state law is more restrictive, every 24 hours, a physician, clinical psychologist, or other authorized licensed independent practitioner primarily responsible for the patient’s ongoing care sees and evaluates the before writing a new order for restraint or seclusion used for the management of violent or self destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others in accordance with hospital policy and law and regulation.

EP6 Orders for restraint used to protect the physical safety of the nonviolent or non-self-destructive patient are renewed in accordance with hospital policy.

PC.03.05.07: The hospital monitors patients who are restrained or secluded.

EP1 Trained physicians, clinical psychologists, or other licensed independent practitioners or staff monitor the condition of patients in restraint or seclusion.

PC.03.05.11: The hospital evaluates and reevaluates the patient who is restrained or secluded.

EP1 A physician, clinical psychologist, or other licensed independent practitioner responsible for the care of the patient evaluates the patient in-person within one hour of the initiation of restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff, or others. A registered nurse or a physician assistant may conduct the in-person evaluation within one hour of the initiation of restraint or seclusion; this individual is trained in accordance with the requirements in PC.03.05.17, EP 3.

EP2 When the in-person evaluation (performed within one hour of the initiation of restraint or seclusion) is done by a trained registered nurse or trained physician assistant, he or she consults with the attending physician, clinical psychologist, or other licensed independent practitioner responsible for the care of the patient as soon as possible after the evaluation, as determined by hospital policy.

EP3 The in-person evaluation, conducted within one hour of the initiation of restraint or seclusion for the management
of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff, or others, includes
the following:
- An evaluation of the patient's immediate situation
- The patient's reaction to the intervention
- The patient's medical and behavioral condition
- The need to continue or terminate the restraint or seclusion

PC.03.05.15: The hospital documents the use of restraint or seclusion.

EP1 Documentation of restraint and seclusion in the medical record includes the following:
- Any in-person medical and behavioral evaluation for restraint or seclusion used to manage violent or self destructive behavior
- A description of the patient’s behavior and the intervention used
- Any alternatives or other less restrictive interventions attempted
- The patient’s condition or symptom(s) that warranted the use of the restraint or seclusion
- The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention
- Individual patient assessments and reassessments
- The intervals for monitoring
- Revisions to the plan of care
- The patient’s behavior and staff concerns regarding safety risks to the patient, staff, and others that necessitated the use of restraint or seclusion
- Injuries to the patient
- Death associated with the use of restraint or seclusion
- The identity of the physician, clinical psychologist, or other licensed independent practitioner who ordered the restraint or seclusion
- Orders for restraint or seclusion
- Notification of the use of restraint or seclusion to the attending physician
- Consultations

PC.04.01.01: The hospital has a process that addresses the patient’s need for continuing care, treatment, and services after discharge or transfer.

EP22 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital informs the patient or the patient’s family of his or her freedom to choose among participating Medicare providers and, when possible, respects the patient’s and family’s preferences when they are expressed. The hospital does not limit the qualified providers that are available to the patient.

EP23 For hospitals that use Joint Commission accreditation for deemed status purposes: When the discharge planning evaluation indicates a need for home health care, the hospital includes in the discharge plan a list of participating Medicare home health agencies (which have requested to be on the list) that are available and serve the patient’s geographic area. For patients enrolled in managed care organizations, the hospital lists home health agencies that have a contract with the managed care organization.

EP24 For hospitals that use Joint Commission accreditation for deemed status purposes: When the discharge planning evaluation indicates a need for post-hospital extended care services, the hospital includes in the discharge plan a list of participating Medicare skilled nursing facilities that are available and in the geographic area requested by the patient. For patients enrolled in managed care organizations, the hospital lists skilled nursing facilities that have a contract with the managed care organization.

EP25 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital documents in the patient’s medical record that the list of home health agencies or skilled nursing facilities was presented to the patient or to the individual acting on the patient’s behalf. The discharge plan identifies disclosable financial interests between the hospital and any home health agency or skilled nursing facility on the list.

PC.04.01.03: The hospital discharges or transfers the patient based on his or her assessed needs and the organization’s ability to meet those needs.

EP1 The hospital begins the discharge planning process early in the patient’s episode of care, treatment, and services.

EP10 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital conducts reassessments of its discharge planning process within its established time frames for reassessment.

EP11 For hospitals that use Joint Commission accreditation for deemed status purposes: The reassessment of the discharge planning process includes a review of discharge plans to determine if the discharge plans meet the needs of patients.

PC.04.01.05: Before the hospital discharges or transfers a patient, it informs and educates the patient about his or her follow-up care, treatment, and services.

EP1 When the hospital determines the patient's discharge or transfer needs, it promptly shares this information with the patient, and also with the patient's family when it is involved in decision making or ongoing care.

EP7 The hospital educates the patient, and also the patient's family when it is involved in decision making or ongoing care, about how to obtain any continuing care, treatment, and services that the patient will need.

Record of Care

RC.01.01.01: The hospital maintains complete and accurate medical records for each individual patient.

EP5 The medical record contains the information needed to support the patient’s diagnosis and condition.

EP6 The medical record contains the information needed to justify the patient’s care, treatment, and services.

EP7 The medical record contains information that documents the course and result of the patient's care, treatment, and services.

EP8 The medical record contains information about the patient’s care, treatment, or services that promotes continuity of care among providers.

EP11 All entries in the medical record are dated.

EP19 For hospitals that use Joint Commission accreditation for deemed status purposes: All entries in the medical record, including all orders, are timed.

RC.01.02.01: Entries in the medical record are authenticated.

EP2 The hospital defines the types of entries in the medical record made by nonindependent practitioners that require countersigning, in accordance with law and regulation.

EP3 The author of each medical record entry is identified in the medical record.

EP4 Entries in the medical record are authenticated by the author. Information introduced into the medical record through transcription or dictation is authenticated by the author.
Note 1: Authentication can be verified through electronic signatures, written signatures or initials, rubber-stamp signatures, or computer key.
Note 2: For paper-based records, signatures entered for purposes of authentication after transcription or for verbal orders are dated when required by law or regulation or hospital policy. For electronic records, electronic signatures will be date-stamped.
Note 3: For hospitals that use Joint Commission accreditation for deemed status purposes: All orders, including verbal orders, are dated and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient, and who, in accordance with hospital policy; law and regulation; and medical staff bylaws, rules, and regulations, is authorized to write orders.

RC.01.03.01: Documentation in the medical record is entered in a timely manner.

EP4 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital records the patient's medical history and physical examination, including updates, in the medical record within 24 hours after registration or inpatient admission but prior to surgery or a procedure requiring anesthesia services.

RC.02.01.01: The medical record contains information that reflects the patient's care, treatment, and services.

EP1 The medical record contains the following demographic information:
Note: Note: If the patient is a minor, is incapacitated, or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision-maker, or legally authorized representative is documented in the medical record.

- The patient's name, address, and date of birth and the name of any legally authorized representative

The patient's communication needs, including preferred language for discussing health care

The patient’s sex

The legal status of any patient receiving behavioral health care services

EP2 The medical record contains the following clinical information:
- The reason(s) for admission for care, treatment, and services
- The patient’s initial diagnosis, diagnostic impression(s), or condition(s)
- Any findings of assessments and reassessments (See also PC.03.01.03, EPs 1 and 8)
- Any allergies to food
- Any allergies to medications
- Any conclusions or impressions drawn from the patient’s medical history and physical examination
- Any diagnoses or conditions established during the patient’s course of care, treatment, and services (including complications and hospital-acquired infections). For psychiatric hospitals using Joint Commission accreditation for deemed status purposes: The diagnosis includes intercurrent diseases (diseases that occur during the course of another disease; for example, a patient with AIDS may develop an intercurrent bout of pneumonia) and the psychiatric diagnoses.
- Any consultation reports
- Any observations relevant to care, treatment, and services
- The patient’s response to care, treatment, and services
- Any emergency care, treatment, and services provided to the patient before his or her arrival
- Any progress notes
- All orders
- Any medications ordered or prescribed
- Any medications administered, including the strength, dose, route, date and time of administration
- Any access site for medication, administration devices used, and rate of administration
- Any adverse drug reactions
- Treatment goals, plan of care, and revisions to the plan of care (See also PC.01.03.01, EP 23)
- Results of diagnostic and therapeutic tests and procedures
- Any medications dispensed or prescribed on discharge
- Discharge diagnosis
- Discharge plan and discharge planning evaluation

EP4 As needed to provide care, treatment, and services, the medical record contains the following additional
information:
- Any advance directives
- Any informed consent, when required by hospital policy
Note: The properly executed informed consent is placed in the patient’s medical record prior to surgery, except in emergencies. A properly executed informed consent contains documentation of a patient’s mutual understanding of and agreement for care, treatment, and services through written signature; electronic signature; or, when a patient is unable to provide a signature, documentation of the verbal agreement by the patient or surrogate decision-maker.
- Any records of communication with the patient, such as telephone calls or e-mail
- Any patient-generated information

RC.02.01.03: The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.

EP1 The hospital documents in the patient’s medical record any operative or other high-risk procedure and/or the administration of moderate or deep sedation or anesthesia.

EP2 A licensed independent practitioner involved in the patient's care documents the provisional diagnosis in the medical record before an operative or other high-risk procedure is performed.

EP3 The patient’s medical history and physical examination are recorded in the medical record before an operative or other high-risk procedure is performed.

EP5 An operative or other high-risk procedure report is written or dictated upon completion of the operative or other high-risk procedure and before the patient is transferred to the next level of care. Note 1: The exception to this requirement occurs when an operative or other high-risk procedure progress note is written immediately after the procedure, in which case the full report can be written or dictated within a time frame defined by the hospital. Note 2: If the practitioner performing the operation or high-risk procedure accompanies the patient from the operating room to the next unit or area of care, the report can be written or dictated in the new unit or area of care.

EP6 The operative or other high-risk procedure report includes the following information: - The name(s) of the licensed independent practitioner(s) who performed the procedure and his or her assistant(s); - The name of the procedure performed; - A description of the procedure; - Findings of the procedure; - Any estimated blood loss; - Any specimen(s) removed; - The postoperative diagnosis

EP7 When a full operative or other high-risk procedure report cannot be entered immediately into the patient’s medical record after the operation or procedure, a progress note is entered in the medical record before the patient is transferred to the next level of care. This progress note includes the name(s) of the primary surgeon(s) and his or her assistant(s), procedure performed and a description of each procedure finding, estimated blood loss, specimens removed, and postoperative diagnosis.

EP8 The medical record contains the following postoperative information: - The patient’s vital signs and level of consciousness (See also PC.03.01.05, EP 1; PC.03.01.07, EP 1) - Any medications, including intravenous fluids and any administered blood, blood products, and blood components - Any unanticipated events or complications (including blood transfusion reactions) and the management of those events

EP9 The medical record contains documentation that the patient was discharged from the post-sedation or postanesthesia care area either by the licensed independent practitioner responsible for his or her care or according to discharge criteria.

EP10 The medical record contains documentation of the use of approved discharge criteria that determine the patient’s readiness for discharge.

EP11 The postoperative documentation contains the name of the licensed independent practitioner responsible for discharge.

RC.02.03.07: Qualified staff receive and record verbal orders.

EP3 Documentation of verbal orders includes the date and the names of individuals who gave, received, recorded, and implemented the orders.

EP4 Verbal orders are authenticated within the time frame specified by law and regulation.

EP6 For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of verbal orders includes the time the verbal order was received.

RC.02.04.01: The hospital documents the patient’s discharge information.

EP3 In order to provide information to other caregivers and facilitate the patient’s continuity of care, the medical
record contains a concise discharge summary that includes the following:
- The reason for hospitalization
- The procedures performed
- The care, treatment, and services provided
- The patient’s condition and disposition at discharge
- Information provided to the patient and family
- Provisions for follow-up care
Note 1: A discharge summary is not required when a patient is seen for minor problems or interventions, as defined by the medical staff. In this instance, a final progress note may be substituted for the discharge summary provided the note contains the outcome of hospitalization, disposition of the case, and provisions for follow-up care.
Note 2: When a patient is transferred to a different level of care within the hospital, and caregivers change, a transfer summary may be substituted for the discharge summary. If the caregivers do not change, a progress note may be used.
Note 3: For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The record of each patient discharged needs to include a discharge summary with the above information. The exceptions in Notes 1 and 2 are not applicable. All patients discharged need to have a discharge summary.

National Patient Safety Goals

NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

EP3 Before starting a patient on warfarin, assess the patient’s baseline coagulation status; for all patients receiving warfarin therapy, use a current International Normalized Ratio (INR) to adjust this therapy. The baseline status and current INR are documented in the medical record. Note: The patient’s baseline coagulation status can be assessed in a number of ways, including through a laboratory test or by identifying risk factors such as age, weight, bleeding tendency, and genetic factors.

EP7 Provide education regarding anticoagulant therapy to prescribers, staff, patients, and families. Patient/family education includes the following:
- The importance of follow-up monitoring
- Compliance
- Drug-food interactions
- The potential for adverse drug reactions and interactions

NPSG.03.06.01: Maintain and communicate accurate patient medication information.

EP1 Obtain information on the medications the patient is currently taking when he or she is admitted to the hospital or is seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications.
Note 1: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definition of medications.
Note 2: It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources will be considered as meeting the intent of the EP.

EP4 Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter (for example, name, dose, route, frequency, purpose).
Note: When the only additional medications prescribed are for a short duration, the medication information the hospital provides may include only those medications. For more information about communications to other providers of care when the patient is discharged or transferred, refer to Standard PC.04.02.01.

EP5 Explain the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter.
Note: Examples include instructing the patient to give a list to his or her primary care physician; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations. (For information on patient education on medications, refer to Standards MM.06.01.03, PC.02.03.01, and PC.04.01.05.)

NPSG.07.03.01: Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals.

EP3 Educate patients, and their families as needed, who are infected or colonized with a multidrug-resistant organism about health care–associated infection prevention strategies.

NPSG.07.05.01: Implement evidence-based practices for preventing surgical site infections.

EP2 Educate patients, and their families as needed, who are undergoing a surgical procedure about surgical site infection prevention.

NPSG.07.06.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).

EP2 Educate patients who will have an indwelling catheter, and their families as needed, on CAUTI prevention and the symptoms of a urinary tract infection.

NPSG.15.01.01: Identify patients at risk for suicide.

EP1 Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.

EP3 When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family.

UP.01.03.01: A time-out is performed before the procedure.

EP5 Document the completion of the time-out.

Waived Testing

WT.05.01.01: The hospital maintains records for waived testing.

EP2 Test results for waived testing are documented in the patient's medical record.

EP3 Quantitative test result reports in the medical record for waived testing are accompanied by reference intervals (normal values) specific to the test method used and the population served.
Note 1: Semiquantitative results, such as urine macroscopic and urine dipsticks, are not required to comply with this element of performance.
Note 2: If the reference intervals (normal values) are not documented on the same page as and adjacent to the waived test result, they must be located elsewhere within the permanent medical record. The result must have a notation directing the reader to the location of the reference intervals (normal values) in the medical record.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.