JHH Ambulatory EOC Rounds Patient Record Review Only

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date and Time of Audit:

  Date

• Location:

• Auditor Name:

Miscellaneous Findings:

• Other Noncompliant Findings?

  Yes

  No

  N/A

Chart Review

Date of Encounter

• Patient MRN:

• Provider Name:

Home Med List

• Home Medication List is created or edited?

  Yes

  No

  N/A

• Staff state process to assure patient/family receive an updated Home<br>Medication List at end of visit--After Visit Summary (AVS) at check-out

  Yes

  No

  N/A

• The provider reviewed the med list in the visit.

  Yes

  No

  N/A

Problem and Allergy List

• An up-to-date problem list is in the medical record

  Yes

  No

  N/A

• An up-to-date allergy list is in the medical record. If no allergies, then the allergy list states none or no allergies.

  Yes

  No

  N/A

Patient Rights

• Patient's preferred language to receive health care information is documented

  Yes

  No

  N/A

Patient Education

• Learning Needs Evaluation completed and documented

  Yes

  No

  N/A

• Keeping You Safe During Surgery and Procedures provided to patient prior to <br> procedure

  Yes

  No

  N/A

• Patient education provided during visit is documented in progress note or <br> patient instructions

  Yes

  No

  N/A

• Patient education on the After Visit Summary (AVS)

  Yes

  No

  N/A

Pain

• Pain documented for the patient visit (Required for visits with a prescriber)

  Yes

  No

  N/A

• Prescriber addressed pain in their note if pain >3 or if the patient desires to have pain addressed during the visit

  Yes

  No

  N/A

MOLST

• Staff can speak to process for assisting when to obtain a MOLST and where a provider can find it

  Yes

  No

  N/A

Orders Requiring Co-Signature

• All orders requiring co-signature were signed by the authorized provider within<br>3 business days (NIPO's, Protocols and Verbal orders)

  Yes

  No

  N/A

Informed Consent/Procedures

• All procedures that require an informed consent have an informed consent completed and scanned into the medical record

  Yes

  No

  N/A

• Informed consent is signed, dated, timed by authorized provider, witness and patient

  Yes

  No

  N/A

• Patient's first and last name, and procedure being performed are on pages one and two of informed consent

  Yes

  No

  N/A

• All sections of informed consent form completed

  Yes

  No

  N/A

• If sedation administered, sedation consent completed

  Yes

  No

  N/A

• Timeout documented

  Yes

  No

  N/A

• The detailed post op note is present and finalized within 7 days post procedure. <br><br> All of the required elements for the brief op note plus:<br> Detailed description of procedure<br> Clinical stage of tumor, as appropriate

  Yes

  No

  N/A

• . Brief op note documented with all required elements immediately after procedure: Surgeon and assistant names<br>Procedure performed Description of findings Post-op diagnosis<br>Estimated blood loss- if applicable<br>Specimens removed- if applicable

  Yes

  No

  N/A

Provider Visit Documentation

• Encounter closed within 14 days

  Yes

  No

  N/A