cab48c23-5e41-43e8-bd29-f8d161512f1c
Record of Care, Treatment, and Services
RC Standards
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
0
0
3
2009 Medical Record Review Audit Tool
2
true
1
100
7a03fd99-0776-4670-aa3a-e93c9cd30396
The [organization] maintains complete and accurate medical records.
RC.01.01.01
Comp & Accur records
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
1
1
3
2
true
1
100
eb548280-723b-4af6-b879-5a49b577ac39
EP 1 The hospital defines the components of a complete medical record.
Defines complete MR
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7a03fd99-0776-4670-aa3a-e93c9cd30396
30
0
2
2
3
0
true
1
100
9860ec88-c6fd-4379-a030-104ff53a455b
EP 4 The medical record contains information unique to the patient, which is used for patient identification.
Information unique to Pat
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7a03fd99-0776-4670-aa3a-e93c9cd30396
30
0
3
2
3
0
true
1
100
37d6c928-5093-48d1-90d0-8ff47dddc312
EP 5 The medical record contains the information needed to support the patient`s diagnosis and condition.
Info to support Pat Dx
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7a03fd99-0776-4670-aa3a-e93c9cd30396
30
0
4
2
3
0
true
4
100
f4ae49c8-0a9d-412c-8bb6-d300bc3be007
EP 6 The medical record contains the information needed to justify the patient`s care, treatment, and services.
Justify care/tx/services
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7a03fd99-0776-4670-aa3a-e93c9cd30396
30
0
5
2
3
0
true
4
100
3c9d8720-e1cc-468a-a082-866e27909f93
EP 7 The medical record contains information that documents the course and result of the patient`s care, treatment, and services.
Course & Result of care
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7a03fd99-0776-4670-aa3a-e93c9cd30396
30
0
6
2
3
0
true
1
100
d7006ccc-5ea7-400f-af0a-56504b780b5c
EP 8 The medical record contains information about the patient`s care, treatment, and services that promotes continuity of care among providers.
Continuity of Care
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7a03fd99-0776-4670-aa3a-e93c9cd30396
30
0
7
2
3
0
true
1
100
388e89d1-0f8b-4e52-8514-91284bc83ca5
EP 9 The hospital uses standardized formats to document the care, treatment, and services it provides to patients.
Standardized formats
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7a03fd99-0776-4670-aa3a-e93c9cd30396
30
0
8
2
3
0
true
1
100
a6fe541c-2b92-448b-9d43-fd78faffbb3b
EP 11 All entries in the medical record are dated.
All entries dated
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7a03fd99-0776-4670-aa3a-e93c9cd30396
30
0
9
2
3
0
true
1
100
00b8af3d-dde6-4eae-a60c-5c37252ceb15
EP 12 The hospital tracks the location of all components of the medical record.
Hosp tracks loc of MR
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7a03fd99-0776-4670-aa3a-e93c9cd30396
30
0
10
2
3
0
true
3
100
a994fa8d-79aa-4c58-9a2b-2e805a010506
EP 13 The hospital assembles or makes available in a summary in the medical record all information required to provide patient care, treatment, and services. (See also MM.01.01.01, EP 1)
Summary info in MR
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7a03fd99-0776-4670-aa3a-e93c9cd30396
30
0
11
2
3
0
true
3
100
badbec0b-695c-4723-9692-d768fbdc0af5
EP 19 For hospitals that use Joint Commission accreditation for deemed status purposes: All entries in the medical record, including all orders, are timed.
Orders time for JCAHO
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7a03fd99-0776-4670-aa3a-e93c9cd30396
30
0
12
2
3
0
true
1
100
b4af32a4-def0-4526-9033-0110dab368e5
Entries in the medical record are authenticated
RC.01.02.01
Entries authenticated
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
13
1
3
Look for signatures after each entry
2
true
1
100
fa53ce5b-41e0-48d1-9360-12b07fe4bb3c
EP 1 Only authorized individuals make entries in the medical record.
Entries by author individ
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
b4af32a4-def0-4526-9033-0110dab368e5
30
0
14
2
3
0
true
1
100
f60b3fc9-7671-4d70-b75e-5c93428cfeaf
EP 2 The hospital defines the types of entries in the medical record made by non-independent practitioners that require counter signing, in accordance with law and regulation.
Type req counter signing
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
b4af32a4-def0-4526-9033-0110dab368e5
30
0
15
2
3
0
true
1
100
874fbc9c-53a9-494e-be66-ec5dd8a90d0e
EP 3 The author of each medical record entry is identified in the medical record.
Author identified
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
b4af32a4-def0-4526-9033-0110dab368e5
30
0
16
2
3
0
true
1
100
b8f58c05-810f-43e0-8e8a-9409f221c91b
EP 4 Entries in the medical record are authenticated by the author. Information introduced into the medical record through transcription or dictation are authenticated by the author.
Entries dictated authen
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
b4af32a4-def0-4526-9033-0110dab368e5
30
0
17
2
3
0
true
1
100
6e02283a-85a9-490b-91dc-a0ad51f51a11
Note 1: Authentication can be verified through electronic signatures, written signatures or initials, rubber-stamp signatures, or computer key.
Note: Authen verified
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
b4af32a4-def0-4526-9033-0110dab368e5
30
0
18
2
3
3
false
1
100
7f0a3ae1-3ccf-4e16-a51e-002eb43828d8
Note 2: For paper-based records, signatures entered for purposes of authentication after transcription or for verbal orders are dated when required by law or regulation or hospital policy. For electronic records, electronic signatures will be date-stamped.
Note: Required by law
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
b4af32a4-def0-4526-9033-0110dab368e5
30
0
19
2
3
3
false
1
100
979c4355-3c38-485b-b093-8c28a8b366e3
EP 5 The individual identified by the signature stamp or method of electronic authentication is the only individual who uses it.
Electronic authentication
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
b4af32a4-def0-4526-9033-0110dab368e5
30
0
20
2
3
0
true
1
100
56de107c-72a3-4135-a87b-f728529ae33f
Documentation in the medical record is entered in a timely manner
RC.01.03.01
Doc entered timely
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
21
1
3
2
true
1
100
0455f10f-d7a4-4165-ae6e-4ef3791fb0af
EP 1 The hospital has a written policy that requires timely entry of information into the medical record. (See also PC.01.02.03, EP 1)
Policy on timely entry
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
56de107c-72a3-4135-a87b-f728529ae33f
30
0
22
2
3
0
true
1
100
9189cc38-d548-4aff-a018-bae8965444b8
EP 2 The hospital defines the time frame for completion of the medical record, which does not exceed 30 days after the patient`s discharge.
Defined time frame
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
56de107c-72a3-4135-a87b-f728529ae33f
30
0
23
2
3
0
true
1
100
ae0a08e5-55a3-44bc-bdb6-6cf9585ab8af
EP 3 The hospital implements its policy requiring timely entry of information into the patient`s medical record. (See also PC.01.02.03, EP 2)
Implements timely policy
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
56de107c-72a3-4135-a87b-f728529ae33f
30
0
24
2
3
0
true
1
100
cc180c9e-e363-4e8d-a0cf-37aa4bdfdab9
EP 4 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital records the patient`s medical history and physical examination, including updates, in the medical record within 24 hours after inpatient admission or registration, but prior to surgery or a procedure requiring anesthesia.
History updated for JCAHO
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
56de107c-72a3-4135-a87b-f728529ae33f
30
0
25
2
3
0
true
1
100
19c9d017-1154-4467-bb76-f820ccbd4d6e
The organization audits it`s medical records
RC.01.04.01
Audits Med Records
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
26
1
3
2
true
1
100
5511baf9-5e77-430e-b9f3-62e75f1cd552
EP 1 The hospital conducts an ongoing review of medical records at the point of care, based on the following indicators: presence, timeliness, legibility (whether handwritten or printed), accuracy, authentication, and completeness of data and information. (See also MS.05.01.03, EP 3)
Conducts ongoing review
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
19c9d017-1154-4467-bb76-f820ccbd4d6e
30
0
27
2
3
0
true
1
100
8e5a28bf-cee8-464d-b78d-12578e1f409a
EP 3 The hospital measures its medical record delinquency rate at regular intervals, but no less than every three months. (See also MS.05.01.03, EP 3)
Measure delinq rate reg
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
19c9d017-1154-4467-bb76-f820ccbd4d6e
30
0
28
2
3
0
true
1
100
0be32a99-58e7-45f7-8b43-70c6e6862844
EP 4 The medical record delinquency rate averaged from the last four quarterly measurements is 50% or less of the average monthly discharge (AMD) rate. Each individual quarterly measurement is no greater than 50% of the AMD rate.
Average last 4 qtrs
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
19c9d017-1154-4467-bb76-f820ccbd4d6e
30
0
29
2
3
0
true
1
100
dfd103f9-828c-4b9d-aba4-604c10b88c54
Organization retains it`s medical records
RC.01.05.01
Organization retains MR
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
30
1
3
2
true
1
100
6829ef91-f135-474e-b0ea-59acbdb1f9a9
EP 1 The retention time of the medical record is determined by its use and hospital policy, in accordance with law and regulation.
MR retention time
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
dfd103f9-828c-4b9d-aba4-604c10b88c54
30
0
31
2
3
0
true
1
100
692aad54-e7a7-4d8d-99e5-d53a62203716
EP 8 Original medical records are not released unless the hospital is responding to law and regulation.
Original MR not released
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
dfd103f9-828c-4b9d-aba4-604c10b88c54
30
0
32
2
3
0
true
1
100
605254f2-d95f-4b87-8c74-ba61c0b66ebb
The medical record contains information that reflects the [patient]`s care, treatment, and services
RC.02.01.01
MR reflects care/tx/serv
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
33
1
3
2
true
1
100
cca3b3aa-613a-4254-beb4-1a01e3e0ebe7
EP 1 The medical record contains the following demographic information:
MR demograph info
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
605254f2-d95f-4b87-8c74-ba61c0b66ebb
30
0
34
2
3
2
true
1
100
dd116d11-9d3e-4781-a058-35a6412182e5
Patient`s name
Patient`s name
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cca3b3aa-613a-4254-beb4-1a01e3e0ebe7
30
0
35
3
3
0
true
1
100
27b271d7-acc2-44cc-9e21-86585a910336
Address
Address
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cca3b3aa-613a-4254-beb4-1a01e3e0ebe7
30
0
36
3
3
0
true
1
100
dbd034da-4696-479c-a6b6-1945210c6ccc
Date of Birth
Date of Birth
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cca3b3aa-613a-4254-beb4-1a01e3e0ebe7
30
0
37
3
3
0
true
1
100
8b503857-d46b-4980-9abe-b5a451b28ed0
Name of any legally authorized representative
Name of legal represen
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cca3b3aa-613a-4254-beb4-1a01e3e0ebe7
30
0
38
3
3
0
true
1
100
a4ffcb2a-1eff-4dae-b930-37b1294e7c24
The patient`s sex
The patient`s sex
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cca3b3aa-613a-4254-beb4-1a01e3e0ebe7
30
0
39
3
3
0
true
1
100
54827709-1e37-4261-8f25-85eaccedc9bc
The legal status of any patient receiving behavioral health care services.
Legal status of BHC
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cca3b3aa-613a-4254-beb4-1a01e3e0ebe7
30
0
40
3
3
0
true
1
100
e39a8e90-cb43-4a61-8365-4bb8d3f48b9d
The patient`s language and communication needs.
Pt language/commun needs
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cca3b3aa-613a-4254-beb4-1a01e3e0ebe7
30
0
41
3
3
0
true
1
100
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
EP 2 The medical record contains the following clinical information:
Contains clinical info
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
605254f2-d95f-4b87-8c74-ba61c0b66ebb
30
0
42
2
3
2
true
1
100
4b576fb2-e315-4729-8835-144af98e6173
The reason(s) for admission for care, treatment, and services.
Reason(s) for care/tx/ser
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
43
3
3
0
true
1
100
ea3f04f3-ecd6-45f2-a5f5-f1125b6b3bca
The patient`s initial diagnosis, diagnostic impression(s), or condition(s).
Initial dx/impres/cond
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
44
3
3
0
true
1
100
edf464b8-23c2-4b04-bab5-bdaccb5245c7
Any findings of assessments and reassessments. (See also PC.01.02.01, EP 1 and PC.03.01.03, EPs 1 and 8)
Finding of assess/reasses
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
45
3
3
0
true
1
100
4acae557-4918-4a43-9e5c-6b4c572ba177
Any allergies to food.
Any allergies to food
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
46
3
3
0
true
1
100
c925e0d4-a2ec-4368-8a6c-104c2a29bbac
Any allergies to medications.
Any allergies to meds
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
47
3
3
0
true
1
100
4b784801-2a29-4e0e-a1c9-335e289b9fbe
Any conclusions or impressions drawn from the patient`s medical history and physical examination.
Conclusions/impressions
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
48
3
3
0
true
1
100
26a75b24-733e-4de2-ac0e-be05ec6568c8
Any diagnoses or conditions established during the patient`s course of care, treatment, and services.
DX during care/tx/service
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
49
3
3
0
true
1
100
c04f14f1-a2b3-46be-8b95-b29e135ad42b
Any consultation reports.
Any consultation reports
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
50
3
3
0
true
1
100
6d6ae0ed-cedd-409c-8274-9a7be770208c
Any observations relevant to care, treatment, and services.
Observ to care/tx/service
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
51
3
3
0
true
1
100
c59cb491-32ec-4db7-8125-e6811b1e94b9
The patient`s response to care, treatment, and services.
Pt resp to care/tx/servic
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
52
3
3
0
true
1
100
5904d5f1-ec8a-4dc0-a5b8-fcaa2ae69e4c
Any emergency care, treatment, and services provided to the patient before his or her arrival.
Emerg care to pat
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
53
3
3
0
true
1
100
9e4132f9-4c98-4caa-a03e-f00d4a80a767
Any progress notes.
Any progress notes
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
54
3
3
0
true
1
100
2fc42e99-6d24-4608-adcf-ace3de1e6e0c
Any medications ordered or prescribed.
Meds ordered/prescrib
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
55
3
3
0
true
1
100
1d8ba0a7-4b2a-459a-b80d-9c54bb0423a7
Any medications administered, including the strength, dose, and route.
Meds administered
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
56
3
3
0
true
1
100
55dc983b-092d-4530-b623-533ebd39e0d7
Any access site for medication, administration devices used, and rate of administration.
Access site for meds
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
57
3
3
0
true
1
100
ab294a63-203f-41f1-b2bc-78f0d97a20bb
Adverse drug reactions.
Adverse drug reactions
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
58
3
3
0
true
1
100
97094ba6-1bb7-4078-956e-b3a02b26df93
Treatment goals, plan of care, and revisions to the plan of care. (See also PC.01.03.01, EP 1 and 23)
Tx goals/plan of care
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
59
3
3
0
true
1
100
39118dba-62bd-43b9-b8b3-1899dfda4e70
Results of diagnostic and therapeutic tests and procedures
Orders for diag tests
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
60
3
3
0
true
1
100
99a4a9dc-3e3c-433d-9328-ce1728fb3805
Any medications dispensed or prescribed on discharge.
Meds dispensed/prescrib
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
61
3
3
0
true
1
100
f86d5926-8b93-4f78-bdcc-19950b95d03a
Discharge Diagnosis
Discharge Diagnosis
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
62
3
3
0
true
1
100
05a938c6-8ab0-4d72-aed6-89e4007745a1
Discharge plan and discharge planning evaluation
DC plan & evaluation
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6f2d5e8b-d87a-41b1-baab-1dc7bf7abd14
30
0
63
3
3
0
true
1
100
50b5a03d-bc99-410f-9d49-8a0f20228058
EP 4 As needed to provide care, treatment, and services, the medical record contains the following additional information:
MR Contains the following
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
605254f2-d95f-4b87-8c74-ba61c0b66ebb
30
0
64
2
3
2
true
1
100
3992260f-6f46-43d8-bbd0-42f4038814a2
Any advance directives. (See also RI.01.05.01, EP 11)
Any advance directives
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
50b5a03d-bc99-410f-9d49-8a0f20228058
30
0
65
3
3
0
true
1
100
88739393-9df4-4274-a2c6-7071a0f358f5
Any informed consent, when required by hospital policy. (See also RI.01.03.01, EP 13)
Any informed consent
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
50b5a03d-bc99-410f-9d49-8a0f20228058
30
0
66
3
3
0
true
1
100
a0923de2-35b9-4db2-95ef-1ca660cd0827
Any records of communication with the patient, such as telephone calls or e-mail.
Records of communication
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
50b5a03d-bc99-410f-9d49-8a0f20228058
30
0
67
3
3
0
true
1
100
ce76edd3-4a9f-482a-8d9c-a077c8c64602
Any patient-generated information
Any pat-generated info
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
50b5a03d-bc99-410f-9d49-8a0f20228058
30
0
68
3
3
0
true
1
100
244369b3-cfe5-42e8-bf86-b48755bfbfeb
EP 21 The medical record of a patient who receives urgent or immediate care, treatment, and services contains all of the following:
Urgent immed care
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
605254f2-d95f-4b87-8c74-ba61c0b66ebb
30
0
69
2
3
2
true
1
100
6283d229-0932-49ab-a912-db7302f4264b
The time and means of arrival
Time and means of arrival
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
244369b3-cfe5-42e8-bf86-b48755bfbfeb
30
0
70
3
3
0
true
1
100
dd99db0b-851b-4292-9cdd-4efa510b3405
Indication that the patient left against medical advice, when applicable.
Indication of Pat AMA
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
244369b3-cfe5-42e8-bf86-b48755bfbfeb
30
0
71
3
3
0
true
1
100
d15f8511-7b83-48fd-b51e-7b051d5274b1
Conclusions reached at the termination of care, treatment, and services, including the patient`s final disposition, condition, and instructions given for follow-up care, treatment, and services.
Conc reached at term
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
244369b3-cfe5-42e8-bf86-b48755bfbfeb
30
0
72
3
3
0
true
1
100
efc3f4b1-89ff-4327-8a09-06f562fb7ffd
A copy of any information made available to the practitioner or medical organization providing follow-up care, treatment, or services.
A copy of any information
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
244369b3-cfe5-42e8-bf86-b48755bfbfeb
30
0
73
3
3
0
true
1
100
ff18a487-e506-494e-858f-a87651672d9a
The [patient]`s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
RC.02.01.03
Doc high-risk procedure
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
74
1
3
2
true
1
100
f6d9c664-23d0-4663-a912-23b8a6a7f757
Elements of Performance
Elements of Performance
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
75
1
3
1
true
1
100
917041c7-2f9c-46cd-9158-d04be3bfedb2
1 The hospital documents in the patient`s medical record any operative or other high-risk procedure and/or the administration of moderate or deep sedation or anesthesia.
1 The hospital documents
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
76
2
3
0
true
1
100
0ae6234d-8e6a-4e97-add9-919d49621704
2 A licensed independent practitioner involved in the patient`s care documents the provisional diagnosis in the medical record before an operative or other high-risk procedure is performed.
2 A licensed independent
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
77
2
3
0
true
1
100
cf4f73a0-3635-428d-8c6e-30f7370cfcf8
3 The patient`s medical history and physical examination are recorded in the medical record before an operative or other high-risk procedure is performed. (See also PC.01.02.03, EP 5)
3 The patient`s medical h
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
78
2
3
0
true
1
100
c161d7ab-e709-4bd9-8d9f-3000eb976483
5 An operative or other high-risk procedure report is written or dictated upon completion of the operative or other high-risk procedure and before the patient is transferred to the next level of care.
5 An operative or other h
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
79
2
3
0
true
1
100
97e1b68b-df05-4eab-bc93-4cbb5826c0bc
Note 1: The exception to this requirement occurs when an operative or other high-risk procedure progress note is written immediately after the procedure, in which case the full report can be written or dictated within a time frame defined by the hospital.
Note 1: The exception
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
80
2
3
3
false
1
100
0eea564a-eb2e-4790-86f4-b9082d7db704
Note 2: If the practitioner performing the operation or high-risk procedure accompanies the patient from the operating room to the next unit or area of care, the report can be written or dictated in the new unit or area of care.
Note 2: If the practition
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
81
2
3
3
false
1
100
e99908ee-bf2b-4c3e-84df-74e66df420fb
EP 6 The operative or other high-risk procedure report includes the following information:
Operative report includes
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
82
2
3
1
true
1
100
3f38e1c9-ccae-4fbc-8bd6-d21a1066c20d
The names of the licensed independent practitioner(s) who performed the procedure and his or her assistants.
Names of LIP
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
e99908ee-bf2b-4c3e-84df-74e66df420fb
30
0
83
3
3
0
true
1
100
b5b95f56-9674-45da-aac4-44a3082b1ebc
The name of the procedure(s) performed
Name of proced perform
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
e99908ee-bf2b-4c3e-84df-74e66df420fb
30
0
84
3
3
0
true
1
100
8837e85a-9b06-4cd1-b4c3-cfd5c21430d4
A description of the procedure(s)
Description of procedure
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
e99908ee-bf2b-4c3e-84df-74e66df420fb
30
0
85
3
3
0
true
1
100
963cff9b-50f2-46a4-af09-7668090cd7cf
Findings of the procedure(s)
Findings of the procedure
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
e99908ee-bf2b-4c3e-84df-74e66df420fb
30
0
86
3
3
0
true
1
100
f883904d-02b6-40f6-b664-042bb4419683
Any estimated blood loss
Any estimated blood loss
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
e99908ee-bf2b-4c3e-84df-74e66df420fb
30
0
87
3
3
0
true
1
100
02991c06-b25a-4f24-a49d-e96d7383d4cb
Any specimen(s) removed
Any specimen(s) removed
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
e99908ee-bf2b-4c3e-84df-74e66df420fb
30
0
88
3
3
0
true
1
100
228c6fa6-7c22-4ccf-9a63-856fc61bebf6
The postoperative diagnosis
Postoperative diagnosis
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
e99908ee-bf2b-4c3e-84df-74e66df420fb
30
0
89
3
3
0
true
1
100
35320d59-73bf-42e2-b1c4-4055ada65a57
EP 7 When a full operative or other high-risk procedure report cannot be entered immediately into the patient`s medical record after the operation or procedure, a progress note is entered in the medical record before the patient is transferred to the next level of care. This progress note includes the name(s) of the primary surgeon and assistants, procedures performed and a description of each procedure finding, estimated blood loss, specimens removed, and postoperative diagnosis.
Entered immed in Pt rec
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
90
2
3
1
true
1
100
c2e02154-d37f-445a-ada0-a727c7621a15
EP 8 The medical record contains the following postoperative information:
MR postoperative note
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
91
2
3
1
true
1
100
8e77546a-8a86-4c5d-a09c-39b582992fce
The patient`s vital signs and level of consciousness. (See also PC.03.01.05, EP 1 and PC.03.01.07, EP 1)
Pt vitals/consciousness
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
c2e02154-d37f-445a-ada0-a727c7621a15
30
0
92
3
3
0
true
1
100
345865d9-4b4f-4d03-a5cc-a57fc103d172
Any medications, including intravenous fluids and any administered blood, blood products, and blood components.
Any meds, includ intraven
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
c2e02154-d37f-445a-ada0-a727c7621a15
30
0
93
3
3
0
true
1
100
1a9e03c1-9434-45e0-98e5-9b9fc263eb1a
Any unanticipated events or complications (including blood transfusion reactions) and the management of those events.
Any unanticipated events
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
c2e02154-d37f-445a-ada0-a727c7621a15
30
0
94
3
3
0
true
1
100
1ed4673a-b294-465c-ac28-888560524506
EP 9 The medical record contains documentation that the patient was discharged from the post-sedation or post-anesthesia care area either by the licensed independent practitioner responsible for his or her care or according to discharge criteria. (See also PC.03.01.07, EP 4)
Post-sedation/post-anesth
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
95
2
3
1
true
1
100
0c634509-e80e-4a30-8313-924758f8ae53
EP 10 The medical record contains documentation of the use of approved discharge criteria that determine the patient`s readiness for discharge.(See also PC.03.01.07, EP 4)
Approved DC criteria
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
96
2
3
1
true
1
100
7eb25ed4-389b-423f-ab38-f1a45b77b232
EP 11 The postoperative documentation contains the name of the licensed independent practitioner responsible for discharge.
Name of LIP at DC
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
97
2
3
1
true
1
100
7ef12eea-ba63-4758-a09d-a01050ddbba4
EP 15 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has to complete an up-to-date operating room register that includes the following:
Operating room register
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
f6d9c664-23d0-4663-a912-23b8a6a7f757
30
0
98
2
3
1
true
1
100
fd6e148e-e7f9-4671-8cc7-3cededd9f4f2
Patient name
Patient name
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7ef12eea-ba63-4758-a09d-a01050ddbba4
30
0
99
3
3
0
true
1
100
93fcc249-ee3e-4bb9-98db-3adf8810755f
Patient hospital identification number
Patient hospital iden #
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7ef12eea-ba63-4758-a09d-a01050ddbba4
30
0
100
3
3
0
true
1
100
1d9c01cd-b351-4448-95ea-e7ef4aac76ed
Date of operation
Date of operation
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7ef12eea-ba63-4758-a09d-a01050ddbba4
30
0
101
3
3
0
true
1
100
aa07c060-65cd-48ff-83c5-fc40e2866463
Inclusive or total time of operation
Total time of Op
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7ef12eea-ba63-4758-a09d-a01050ddbba4
30
0
102
3
3
0
true
1
100
bcd63f61-edc7-4e7e-8a70-55d79b67658e
Name of surgeon and any assistants
Name of surgeon/assist
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7ef12eea-ba63-4758-a09d-a01050ddbba4
30
0
103
3
3
0
true
1
100
e2ea5bda-a065-46fd-b1bf-e803e9a95eca
Name of nursing personnel
Name of nursing personnel
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7ef12eea-ba63-4758-a09d-a01050ddbba4
30
0
104
3
3
0
true
1
100
19bae7a1-3a66-463f-8b50-32ebbdd54e51
Type of anesthesia used and name of person administering it
Type of anesthesia/name
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7ef12eea-ba63-4758-a09d-a01050ddbba4
30
0
105
3
3
0
true
1
100
33d0d525-42d6-41cf-9f3a-3736001d6857
Operation performed
Operation performed
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7ef12eea-ba63-4758-a09d-a01050ddbba4
30
0
106
3
3
0
true
1
100
33dffcfb-412d-4488-b327-0df963a962f5
Pre and post operation diagnosis
Pre and post dx
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7ef12eea-ba63-4758-a09d-a01050ddbba4
30
0
107
3
3
0
true
1
100
0cb59cc4-635d-4ba3-b09c-91f36eabd736
Age of patient
Age of patient
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7ef12eea-ba63-4758-a09d-a01050ddbba4
30
0
108
3
3
0
true
1
100
830f372d-addc-4b73-a8b0-829700aaa491
Note: A post operation summary may be considered equivalent if all items listed in this element of performance are included
Post op sum equivalent
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
7ef12eea-ba63-4758-a09d-a01050ddbba4
30
0
109
3
3
3
false
1
100
b65bd18d-9289-49e4-831f-217b8ae14916
The medical record contains documentation of the use of restraint and/or seclusion.
RC.02.01.05
Doc restraint/seclusion
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
110
1
3
2
true
1
100
0f64e11f-c1d2-49fa-84d0-ba83037aeba7
EP 1 The hospital documents the use of restraint for non-behavioral health purposes in the medical record, including the following:
Restraint for non-BHealth
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
b65bd18d-9289-49e4-831f-217b8ae14916
30
0
111
2
3
2
true
1
100
48d73a01-3031-45b0-899a-ecebc5324521
Orders for use
Orders for use
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
0f64e11f-c1d2-49fa-84d0-ba83037aeba7
30
0
112
3
3
0
true
1
100
322ae775-7f2f-400c-81c3-34766d07ead4
Results of patient monitoring
Results of pt monitoring
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
0f64e11f-c1d2-49fa-84d0-ba83037aeba7
30
0
113
3
3
0
true
1
100
0e9d230e-0f36-4c51-9d07-49aeab496b5a
Reassessment
Reassessment
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
0f64e11f-c1d2-49fa-84d0-ba83037aeba7
30
0
114
3
3
0
true
1
100
d8729f17-4e1a-4b7e-8bdc-f0240dfecff3
Unanticipated changes in the patient`s condition. (See also PC.03.02.03, EP 1 and PC.03.02.07, EPs 1 and 2)
Unanticipated changes
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
0f64e11f-c1d2-49fa-84d0-ba83037aeba7
30
0
115
3
3
0
true
1
100
d252ec61-1deb-4ff5-9052-3c78a5fed972
EP 2 The hospital documents any use of restraint protocol(s) for non-behavioral health purposes in the medical record. (See also PC.03.02.05, EPs 1 and 11)
Restra protocol non BH
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
b65bd18d-9289-49e4-831f-217b8ae14916
30
0
116
2
3
1
true
1
100
4901a6fa-8f29-45ec-9924-d8f4436c73d3
EP 3 The hospital documents the use of restraint and/or seclusion for behavioral health purposes in the medical record, including the following:
Restr/seclusion for BH
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
b65bd18d-9289-49e4-831f-217b8ae14916
30
0
117
2
3
2
true
1
100
8e8c0dec-cbee-4934-a2e9-0bf28902ca26
Each episode of restraint and/or seclusion
Each episode of restraint
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
118
3
3
0
true
1
100
155dd96e-4212-4f38-8826-73af39e66942
The circumstances that led to the use of restraint and/or seclusion
Circumstances lead to
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
119
3
3
0
true
1
100
d3ab148d-b2e8-4e36-91ff-6741581e9e56
Consideration or failure of non physical interventions
Failure of non phy interv
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
120
3
3
0
true
1
100
dd243ade-5a94-47dd-bfcd-9d2425924197
The rationale for the type of physical intervention used.
Rationale for phy interv
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
121
3
3
0
true
1
100
bba27485-e751-4b44-91a0-458e0e3652de
Written orders for the use of restraint and/or seclusion. (See also PC.03.03.13, EPs 1-3)
Written orders for use
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
122
3
3
0
true
1
100
81498e12-0dd1-4881-91ec-195bfceaba17
Each verbal order received from a licensed independent practitioner. (See also PC.03.03.17, EP 1)
Each VO recvd from LIP
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
123
3
3
0
true
1
100
0a7f4750-66a3-4161-aa0b-1f4f14c72427
Each in-person evaluation and reevaluation of the patient.
Each in-person evaluation
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
124
3
3
0
true
1
100
dc4e87c3-27d0-426e-8e4b-7ae732def3cc
Each 15-minute assessment of the patient`s status. (See also PC.03.03.07, EP 5)
Each 15-minute assessment
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
125
3
3
0
true
1
100
bd0f6366-6501-481e-9689-dfbb8feda36b
Continuous monitoring of the patient. (See also PC.03.03.25, EPs 1 and 2)
Continuous monitoring Pt
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
126
3
3
0
true
1
100
0f1119d6-7ac0-46a1-9da4-5dac85baeddf
Any pre-existing medical conditions or any physical disabilities that would place the patient at greater risk during restraint and/or seclusion.
Pre-existing medical con
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
127
3
3
0
true
1
100
8cb15f28-5d10-44ce-a7b7-6e1c8b653aa1
Any history of sexual or physical abuse that would place the patient at greater psychological risk during restraint and/or seclusion.
Hx of sexual/phy abuse
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
128
3
3
0
true
1
100
537c0722-592d-40c3-84a6-8e558b4e3a41
That the patient and/or the patient`s family was informed of the hospital`s policy on the use of behavioral restraint and/or seclusion.
Pt and/or fam informed
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
129
3
3
0
true
1
100
08b14f85-139e-4006-932d-412b4097de53
That the patient`s family was notified of the use of restraint and/or seclusion.
Family notified of use
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
130
3
3
0
true
1
100
dca698fe-589a-42f0-a41c-826a98093a01
Behavior criteria for discontinuing restraint and/or seclusion.
Criteria discontinued
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
131
3
3
0
true
1
100
d2d5bb1b-5c6c-42b5-b1d8-a780d3f29b3c
That the patient was informed of the behavior criteria he or she needed to meet in order for restraint and/or seclusion to be discontinued.
Pt informed of criteria
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
132
3
3
0
true
1
100
2404ed58-1937-4734-9412-0ac25ebef9e8
Assistance provided to the patient to help him or her meet the behavior criteria for discontinuing the use of restraint and/or seclusion
Assistance provided to Pt
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
133
3
3
0
true
1
100
8b979b29-f1c8-4129-873d-574d2f9e4c3d
Debriefing the patient with staff following an episode of restraint and/or seclusion. (See also PC.03.03.29, EP 1)
Debriefing the patient
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
134
3
3
0
true
1
100
5f3115d5-8421-4933-a0c8-7614b1c97ab5
Any injuries the patient sustained and the treatment for these injuries
Injuries sustained to pt
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
135
3
3
0
true
1
100
b25cab07-3b5d-4277-bcdc-3e32798d179d
The patient`s death, should this occur while the patient is under the care of the hospital.
Pt death while under care
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
4901a6fa-8f29-45ec-9924-d8f4436c73d3
30
0
136
3
3
0
true
1
100
b7dfa3b5-26a5-4378-9f9f-e26dfcf0c0c7
EP 4 The method(s) used to document restraint and/or seclusion facilitates the collection and analysis of data for performance improvement activities.
Collection/analy of data
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
b65bd18d-9289-49e4-831f-217b8ae14916
30
0
137
2
3
0
true
1
100
6678b1e9-3565-4e1c-a57f-20611bdb30f0
The medical record contains a summary list for each [patient] who receives continuing ambulatory care services
RC.02.01.07
Summary list
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
138
1
3
2
true
1
100
1382540a-367e-4a03-b11a-1c0801b4c01e
EP 1 A summary list is initiated for the patient by his or her third visit.
Summary list by 3rd visit
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6678b1e9-3565-4e1c-a57f-20611bdb30f0
30
0
139
2
3
1
true
1
100
13630a87-fa60-4ec4-88e8-cc77c62f4c89
EP 2 The patient`s summary list contains the following information:
Summary list contains
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6678b1e9-3565-4e1c-a57f-20611bdb30f0
30
0
140
2
3
2
true
1
100
4b903ba4-882d-4880-bb49-6fc8f0a42e6e
Any significant medical diagnoses and conditions
Significant med dx/cond
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
13630a87-fa60-4ec4-88e8-cc77c62f4c89
30
0
141
3
3
0
true
1
100
59e7b368-6a83-47e1-b386-f612e731fd3f
Any significant operative and invasive procedures
Operative Invasive proced
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
13630a87-fa60-4ec4-88e8-cc77c62f4c89
30
0
142
3
3
0
true
1
100
9bbbe75e-02b6-4701-9a55-30fc234a6ead
Any adverse and allergic drug reactions
Allergic drug reactions
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
13630a87-fa60-4ec4-88e8-cc77c62f4c89
30
0
143
3
3
0
true
1
100
fc319fb4-3a03-4849-b2b5-2074593d6a02
Any current medications, over-the-counter medications, and herbal preparations
Current meds/herbal prep
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
13630a87-fa60-4ec4-88e8-cc77c62f4c89
30
0
144
3
3
0
true
1
100
793dc1da-9c31-4605-b986-32adc8dda328
EP 3 The patient`s summary list is updated whenever there is a change in diagnoses, medications, or allergies to medications, and whenever a procedure is performed.
Updated when changed
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6678b1e9-3565-4e1c-a57f-20611bdb30f0
30
0
145
2
3
0
true
1
100
f2f5a3fe-ebc3-41c6-a058-6a39a1653975
EP 4 The summary list is readily available to practitioners who need access to the information of patients who receive continuing ambulatory care services in order to provide care, treatment, and services.
Readily avail to practit
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
6678b1e9-3565-4e1c-a57f-20611bdb30f0
30
0
146
2
3
0
true
1
100
d35eb8df-6308-4e70-91a8-25a9b1deec8d
Qualified staff receive and record verbal orders
RC.02.03.07
Qualified staff receive a
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
147
1
3
2
true
1
100
511ba929-de4b-4223-a6e9-39c3d6766bca
EP 1 The hospital identifies in writing the staff who are authorized to receive and record verbal orders, in accordance with law and regulation.
Identifies staff authoriz
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
d35eb8df-6308-4e70-91a8-25a9b1deec8d
30
0
148
2
3
0
true
1
100
10b00b2c-5ddd-4f56-8846-18799bfb8086
EP 2 Only authorized staff receive and record verbal orders.
Author staff records VO
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
d35eb8df-6308-4e70-91a8-25a9b1deec8d
30
0
149
2
3
0
true
1
100
c8d8604e-4a4b-4c3c-902c-518a54c466fd
EP 3 Documentation of verbal orders includes the date and the names of individuals who gave, received, recorded, and implemented the order.
Includes date/name of per
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
d35eb8df-6308-4e70-91a8-25a9b1deec8d
30
0
150
2
3
0
true
1
100
43722309-aeca-4f21-aab7-93cb2fd9c3b2
EP 4 Verbal orders are authenticated within the time frame specified by law and regulation.
Verbal orders authent
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
d35eb8df-6308-4e70-91a8-25a9b1deec8d
30
0
151
2
3
0
true
1
100
f650608c-e80d-4ba8-ae46-632edf536560
Note 1: For hospitals that use Joint Commission accreditation for deemed status purposes: If there is no state law that designates a specific time frame for authentication of verbal orders, the verbal orders are authenticated within 48 hours.
VO auth w/in 48 hrs
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
d35eb8df-6308-4e70-91a8-25a9b1deec8d
30
0
152
2
3
3
false
1
100
54cbcf24-fcca-4358-b98f-226d7577a347
Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: In some instances, the ordering practitioner may not be able to authenticate his or her verbal order (for example, the ordering practitioner gives a verbal order that is written and transcribed, and then he or she is “off duty” for the weekend or an extended period of time). In such cases, for a temporary period expiring on January 26, 2012, it is acceptable for another practitioner who is responsible for the patient’s care to authenticate the verbal order of the ordering practitioner.
Other auth w/in 48 hrs
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
d35eb8df-6308-4e70-91a8-25a9b1deec8d
30
0
153
2
3
3
false
1
100
7cceb9f4-35b6-404f-8d91-6041ee571812
EP 6 For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of verbal orders includes the time the verbal order was received.
Time VO received
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
d35eb8df-6308-4e70-91a8-25a9b1deec8d
30
0
154
2
3
0
true
1
100
c2cc3b24-6124-435e-a19c-83bb29795e6d
The [organization] documents the [patient]`s discharge information
RC.02.04.01
Doc PT DC info
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
cab48c23-5e41-43e8-bd29-f8d161512f1c
30
0
155
1
3
2
true
1
100
eedec59e-b803-4190-ba73-8b6455bac4a4
EP 3 In order to provide information to other caregivers and facilitate the patient`s continuity of care, the medical record contains a concise discharge summary that includes the following:
Med Rec contains:
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
c2cc3b24-6124-435e-a19c-83bb29795e6d
30
0
156
2
3
2
true
1
100
e93f0857-0c7c-47f8-a53d-c7a6a4dae3b8
The reason for hospitalization
Reason for hospitalizatio
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
eedec59e-b803-4190-ba73-8b6455bac4a4
30
0
157
3
3
0
true
1
100
9d3cb7e9-f87a-474a-80eb-479b74a20e00
The procedures performed
The procedures performed
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
eedec59e-b803-4190-ba73-8b6455bac4a4
30
0
158
3
3
0
true
1
100
7a4d45fd-a9b6-4132-b59d-98bb9b31e18d
The care, treatment, and services provided
Care, tx, services
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
eedec59e-b803-4190-ba73-8b6455bac4a4
30
0
159
3
3
0
true
1
100
efc71356-51e2-41d9-aa62-3157845d74d8
The patient`s condition and disposition at discharge
Pt cond/dis at DC
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
eedec59e-b803-4190-ba73-8b6455bac4a4
30
0
160
3
3
0
true
1
100
bc45591a-7bf3-489f-8a57-bca1be8b5218
Information provided to the patient and family
Info provided to family
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
eedec59e-b803-4190-ba73-8b6455bac4a4
30
0
161
3
3
0
true
1
100
d5754afe-2a22-4909-bdaf-326e7f9aaf21
Provisions for follow up care
Provisions for f/up care
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
eedec59e-b803-4190-ba73-8b6455bac4a4
30
0
162
3
3
0
true
1
100
f0daa916-40d5-4d2c-9910-a2cddbe0de35
Note 1: A discharge summary is not required when patients are seen for minor problems or interventions, as defined by the medical staff. In this instance, a final progress note may be substituted for the discharge summary.
Final Pro Note can sub
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
c2cc3b24-6124-435e-a19c-83bb29795e6d
30
0
163
2
3
3
false
1
100
d2b2b631-315b-43f6-8957-4d6d4371a0dd
Note 2: When a patient is transferred to a different level of care within the hospital and caregivers change, a transfer summary may be substituted for the discharge summary. If the caregivers do not change, a progress note may be used.
Transfer summary
0
cab48c23-5e41-43e8-bd29-f8d161512f1c
c2cc3b24-6124-435e-a19c-83bb29795e6d
30
0
164
2
3
3
false
1
100