Other Noncompliant Findings?
Home Medication List is created or edited?
Staff state process to assure patient/family receive an updated Home
Medication List at end of visit--After Visit Summary (AVS) at check-out
The provider reviewed the med list in the visit.
An up-to-date problem list is in the medical record
An up-to-date allergy list is in the medical record. If no allergies, then the allergy list states none or no allergies.
Patient's preferred language to receive health care information is documented
Learning Needs Evaluation completed and documented
Keeping You Safe During Surgery and Procedures provided to patient prior to
Patient education provided during visit is documented in progress note or
Patient education on the After Visit Summary (AVS)
Pain documented for the patient visit (Required for visits with a prescriber)
Prescriber addressed pain in their note if pain >3 or if the patient desires to have pain addressed during the visit
Staff can speak to process for assisting when to obtain a MOLST and where a provider can find it
All orders requiring co-signature were signed by the authorized provider within
3 business days (NIPO's, Protocols and Verbal orders)
All procedures that require an informed consent have an informed consent completed and scanned into the medical record
Informed consent is signed, dated, timed by authorized provider, witness and patient
Patient's first and last name, and procedure being performed are on pages one and two of informed consent
All sections of informed consent form completed
If sedation administered, sedation consent completed
The detailed post op note is present and finalized within 7 days post procedure.
All of the required elements for the brief op note plus:
Detailed description of procedure
Clinical stage of tumor, as appropriate
. Brief op note documented with all required elements immediately after procedure: Surgeon and assistant names
Procedure performed Description of findings Post-op diagnosis
Estimated blood loss- if applicable
Specimens removed- if applicable
Encounter closed within 14 days