Audit

GENERAL ELEMENTS OF CARE

Specimens are labeled in the presence of the patient?

Paper/Information with protected health information is out of view; computers and workstations are locked.

All crash cart checks are complete including log - staff can articulate performance in a code.

Patient assessments:
* Admission assessment
* reassessment
* education documentation
* pain management
* falls
* allergies

Access of medical record for consults, labs/tests, interdisciplinary notes, advance directives, etc.

Hand off Communication procedures are performed/articulated?

Team Members are prepared through education:
*competencies
*orientation
*in servicing

National Patient Safety Goals - How are they applied in the area?

Universal Protocol for ALL invasive procedures: pre-procedure verification; site marking; time-out.

History/Physical within 24 hours, operative notes complete - immediately.

Abbreviations - Not to use

What is the Adverse Event process?

Patient c/o process?

Organ donation procedures?

PROVISION OF CARE TREATMENT AND SERVICES

Are there any alarms sounding that staff is not attending to in a timely manner.

RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

Patients and families properly informed of their rights.
*. Rights and Responsibilities statement

Family guides provided to all families on admissions.

WAIVED TESTING / POINT OF CARE TESTING

Point of Care testing lab controls documented and control solution labeled & dated.
*. Reagents, i Stat analyzes, glucometers, GEMS

Point of Care Testing Quality Control:
*. Consistently and correctly documented
*. Dates missing initials
*. Performed by qualified person
*. Out of range is followed
*. Logged numbers match bottle ID numbers

DESCRIBE THE DEPARTMENTS RESPONSE TO YOUR ARRIVAL

Greet the team with smiles and introductions.

Have a space designated for the team to conduct interviews and file reviews.

Promptly deliver materials required for review to the tracer team.

Any additional comments regarding positive or suboptimal issues observed during the tracer.

Surveyors Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.