• 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

  • 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: Veronica Johnson- cell: 443-858-5581, pager 410-434-1504

Surveyor Team

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

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

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

  • MR# of charts reviewed:

Additional Information

  • Summary of Major Concerns/Issues

  • Positive/Compliments to Individuals

  • Additional Notes

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