JHH The Joint Commission Triennial Survey

• The Joint Commission Triennial Survey Guidelines for taking notes: Note the name and history number of any patient involved in tracer activity Staff information: note name, role, unit, and badge number where possible of anyone the surveyor speaks to and/or anyone whose notes they review in a chart Note anytime the location changes Write verbatim notes (questions/issues/suggestions made by the surveyor) Please note the top 3-5 issues in the Additional Information section at the conclusion of your tracer

• Document No.

• Site/Area (Inpatient, Ambulatory, Behaviorlal, Life Safetyetc.)

• Conducted on

  Date

• Prepared by

Quick Reference Phone Numbers Command Center 5-3333 Dana Moore- cell 443-250-7398 Command Center Fax Number: 4-1115 Susan Franklin cell 443-804-0630 Tameria Joy- cell: 410-227-4515 Email: grp-CommandCenter@exchange.johnshopkins.edu Veronica Johnson- cell: 443-858-5581, pager 410-434-1504

Surveyor Team

• Surveyor Name/ Title:<br>Escort Name:<br>Scribe Name:

  Safe

  At Risk

  N/A

• Survey Area (Note when location changes)- Questions/Issues/Suggestions made by Surveyor<br>Summary Notes and PATIENT NAME/HISTORY# BEING TRACED<br><br>

  Safe

  At Risk

  N/A

• Name of any staff interviewed: Name,Role, Badge #

  Safe

  At Risk

  N/A

• MR# of charts reviewed:

  Safe

  At Risk

  N/A

Additional Information

• Summary of Major Concerns/Issues

  Safe

  At Risk

  N/A

• Positive/Compliments to Individuals

  Safe

  At Risk

  N/A

• Additional Notes

  Safe

  At Risk

  N/A