TJC Audit

• Conducted on

  Date

• Prepared by

  Select Battick, Kentlee Belcher, Sherry Jagdeo, Aruna Jenkins, Carol Ann Kochman, Kristina Lawrence, Kay Long, Corrie Messick, Julie Mize, Chris Perez, Julie Perry, Carolyn Renn, Kathy Spence, Amy other (enter name on next page)

  • Battick, Kentlee
  • Belcher, Sherry
  • Jagdeo, Aruna
  • Jenkins, Carol Ann
  • Kochman, Kristina
  • Lawrence, Kay
  • Long, Corrie
  • Messick, Julie
  • Mize, Chris
  • Perez, Julie
  • Perry, Carolyn
  • Renn, Kathy
  • Spence, Amy
  • other (enter name on next page)

• Location (select one)

  Select 7N 7S 8N 8S Cardiology (outpatient clinic) CDU CVICU CVOR Dialysis Emergency Center Infusion Center Interventional Radiology Main OR NICU PACU PCU Pharmacy PICU Pre OP Radiology SPU Transport OCC - Brandon OCC - East Lake OCC - Fort Myers OCC - Lakeland OCC - Pasco OCC- Tampa Infusion OCC - Tampa SPU/MRI OCC - Sarasota OCC - South Tampa other (specify on next page)

  • 7N
  • 7S
  • 8N
  • 8S
  • Cardiology (outpatient clinic)
  • CDU
  • CVICU
  • CVOR
  • Dialysis
  • Emergency Center
  • Infusion Center
  • Interventional Radiology
  • Main OR
  • NICU
  • PACU
  • PCU
  • Pharmacy
  • PICU
  • Pre OP
  • Radiology
  • SPU
  • Transport
  • OCC - Brandon
  • OCC - East Lake
  • OCC - Fort Myers
  • OCC - Lakeland
  • OCC - Pasco
  • OCC- Tampa Infusion
  • OCC - Tampa SPU/MRI
  • OCC - Sarasota
  • OCC - South Tampa
  • other (specify on next page)

Patient Information

• Patient name

• MR number (6 or 7 digit #)

• FIN number (8 digit #)

• Room number

• Staff involved (list all, including surveyor)

• Notes (list main topics reviewed)

• Photos (if necessary)

  Media

• Was the interview/survey completed without any issues or concern identified?

  Yes

  No

  N/A

• Summary of main issues or concerns identified:

• Additional photos (if necessary)

  Media