MMH TJC - SMT - Mock Survey

• Audit Title

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

GENERAL ELEMENTS OF CARE

• Specimens are labeled in the presence of the patient?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Patient assessments:<br> * Admission assessment<br> * reassessment<br> * education documentation<br> * pain management<br> * falls<br> * allergies

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Hand off Communication procedures are performed/articulated?<br>

  Yes

  No

  N/A

• Team Members are prepared through education:<br> *competencies<br> *orientation<br> *in servicing

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Abbreviations - Not to use

  Yes

  No

  N/A

• What is the Adverse Event process?

  Yes

  No

  N/A

• Patient c/o process?

  Yes

  No

  N/A

• Organ donation procedures?

  Yes

  No

  N/A

PROVISION OF CARE TREATMENT AND SERVICES

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

  Yes

  No

  N/A

RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

• Patients and families properly informed of their rights.<br> *. Rights and Responsibilities statement

  Yes

  No

  N/A

• Family guides provided to all families on admissions.

  Yes

  No

  N/A

WAIVED TESTING / POINT OF CARE TESTING

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

DESCRIBE THE DEPARTMENTS RESPONSE TO YOUR ARRIVAL

• Greet the team with smiles and introductions.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Promptly deliver materials required for review to the tracer team.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Surveyors Signature

  Sign