Joint Commission MockTracer: Procedure Area

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Informed Consent and Patient Education

• Is there a completed procedural informed consent?

  Yes

  No

  N/A

• Is there documentation of patient education?

  Yes

  No

  N/A

History and Physical

• Does the H&P document: Physical exam of body system relevant to procedure?

  Yes

  No

  N/A

• Does the H&P document: Review of relevant laboratory/diagnostic data?

  Yes

  No

  N/A

• Does the H&P document: Patient history?

  Yes

  No

  N/A

• Does the H&P document: Diagnosis?

  Yes

  No

  N/A

• Does the H&P document: Plan of care?

  Yes

  No

  N/A

• If the H&P was completed >24 hours prior to procedure, is there an H&P update note completed within 24 hours prior to procedure?

  Yes

  No

  N/A

Anesthesia Sedation Assessment

• Pre-anesthesia sedation assessment is completed- heart, lungs, airway, and ASA classification?

  Yes

  No

  N/A

• Post-anesthesia evaluation documented?

  Yes

  No

  N/A

Immediate Post-OP note/Post Procedure Note

• Does post-op note address all 6 required elements: 1) Surgeon and assistant(s) names, 2) procedure, 3) findings, 4) post-op diagnosis 5) estimated blood loss, 6) specimens. ( must be written before transfer to PACU or sending unit)

  Yes

  No

  N/A

Pre-Procedure Verification Process

• When the patient is in the Pre-procedure area, is a standardized list used to review and verify that the following items are available and accurately match the patient? <br>1) Patient identity, procedure & side/site verified.<br>2) Relevant documentation (H&P, nsg assessment, Pre- anesthesia assess)<br>3) Accurately completed and signed/dated/timed procedure consent form.<br>4) Correct and properly labeled diagnostic and radiology test results<br>5) Any required blood products, implants, devices or special equipment available

  Yes

  No

  N/A

Site Marking

• Is the procedure site marked with the provider's initials?

  Yes

  No

  N/A

• Is the site marked before the patient is moved to the procedure location?

  Yes

  No

  N/A

Time Out

• Is time-out conducted prior to starting procedure?

  Yes

  No

  N/A

• Does the time-out have the following characteristics:<br>1) Involves the immediate members of the procedure team including the proceduralist(s)- Can be the fellow, the anesthesia providers, the circulating nurse, the OR technician, and other participants as appropriate for the procedure, who will be participating in the procedure at its inception.<br>2) Involves interactive verbal communication between all team members.

  Yes

  No

  N/A

• does the time-out address all of the following:<br>1) Correct pt identification<br>2) Confirmation that correct site & side are marked<br>3) An accurate procedural consent form<br>4) Agreement on procedure(s) to be done<br>5) Correct patient position<br>6) Site mark visible after prep and draping<br>7) Resolution of any conflicts in information<br>8) Relevant images and results are properly labeled and appropriately displayed <br>9) Need to administer antibiotics or fluids for irrigation purposes<br>10) Safety precautions based on pt history and/or medication use

  Yes

  No

  N/A

• Was the time-out documented?

  Yes

  No

  N/A

NPSG: Medication Labeling

• Are empty syringes and/or containers labeled immediately after filling?

  Yes

  No

  N/A

• Do labels include: <br>1) medication name<br>2) Strength<br>3) preparation date<br>4) amount (if not apparent from container)

  Yes

  No

  N/A

Documentation

• Every signature is dated and timed

  Yes

  No

  N/A

• Home medication list completed

  Yes

  No

  N/A

• Discharge instructions documented

  Yes

  No

  N/A

• Home medication list updated as appropriate

  Yes

  No

  N/A

• Advance directives documentation completed

  Yes

  No

  N/A