JHH TJC Mock Triennial Survey Scribe Tool

• 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 Number Virtual Command Center: Veronica Johnson 410-502-2133

Surveyor Team

• Surveyor Name:

• Scribe Name:

• Staff Interviewed (include name, role and badge #):

• Survey Area (Note when location changes):

• MRN# of Charts Reviewed:

Tracer Information

• Verbatim Notes:

• Add media

  Media

• Summary of Major Concerns/ Issues:

• Add media

  Media

• Positive/ Compliments to Individuals:

• Add media

  Media

• Additional Notes:

• Add media

  Media