d452d077-4a41-4eda-8e5e-3de3cec210c2
ASSESSMENT OF CARE/SERVICE
Assess of Care/Service
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
0
0
3
2
true
1
100
b5e9ace6-0ba4-4aea-bcfc-3cc4c0077de7
Initial nursing assessment completed within 24 hours of admission
Initial nursing assess
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
1
1
3
0
true
1
100
30c08a20-40c3-4833-b3be-feb2966cf537
H & P available on medical record or electronic format within 24 hours of admission
H&P available w/in 24hrs
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
2
1
3
0
true
1
100
3c5a6b91-05d8-4c3a-8aee-6ae1b4e3c669
H & P reviewed/updated if completed prior to admission or before outpatient surgery
H&P reviewed/updated
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
3
1
3
0
true
1
100
5fd2d1e8-cc9e-4a81-a92b-87810410c0af
H&P over 30 days from adm or outpt. Surgery –cannot be older than 30 days before admission or outpatient surgery
H&P over 30 days from adm
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
4
1
3
0
true
1
100
2669ffb8-552a-4817-bd23-eed81972fb36
Initial assessment/screening:
Initial assessment/screen
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
5
1
3
1
true
1
100
e9292467-1aa5-404f-85f1-46776d766443
Pain
Pain
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
2669ffb8-552a-4817-bd23-eed81972fb36
24
0
6
2
3
0
true
1
100
fee81f62-fb87-42c4-8dfa-b69456f1043b
Nutritional
Nutritional
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
2669ffb8-552a-4817-bd23-eed81972fb36
24
0
7
2
3
0
true
1
100
277bdda7-d7c6-4c88-b543-382134e26790
Functional
Functional
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
2669ffb8-552a-4817-bd23-eed81972fb36
24
0
8
2
3
0
true
1
100
a173cec6-ccfa-467d-a3a3-07e3251037ce
Plan of care with individual patient goals/needs completed within 24 hrs
Plan of care with individ
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
9
1
3
0
true
1
100
308f6f50-db8a-4352-a239-a4bd952b52d4
Plan of care interdisciplinary
Plan of care interdiscip
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
10
1
3
0
true
1
100
6f180551-437d-4d0c-b397-de2002ca86db
Patient/family education documented
Patient/family education
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
11
1
3
0
true
1
100
fa4af216-ca03-4dbb-9f95-bb5b47c46153
Evidence of reassessments and plan of care revisions
Evidence of reassessments
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
12
1
3
0
true
1
100
7b43685b-b05b-4020-b7f4-5ae77858d3d9
Evidence of plan for discharge/transfer
Plan for DC/Transfer
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
13
1
3
0
true
1
100
8866e855-b65f-4bb5-ae4e-38eb8959e66b
Spiritual needs documented
Spiritual needs document
0
d452d077-4a41-4eda-8e5e-3de3cec210c2
d452d077-4a41-4eda-8e5e-3de3cec210c2
24
0
14
1
3
0
true
1
100
83c10054-eb06-4d7b-beba-998aa8e3be37
COMMUNICATION/DOCUMENTATION
Communication/Documen
0
83c10054-eb06-4d7b-beba-998aa8e3be37
83c10054-eb06-4d7b-beba-998aa8e3be37
25
1
0
0
3
2
true
1
100
284aad4c-e58c-4f73-a38a-f3b1e374e76c
All entries in the medical record:
All entries in the medica
0
83c10054-eb06-4d7b-beba-998aa8e3be37
83c10054-eb06-4d7b-beba-998aa8e3be37
25
1
1
1
3
2
true
1
100
d5bcf8a8-65db-48b6-8bb8-7872e396f904
Signed
Signed
0
83c10054-eb06-4d7b-beba-998aa8e3be37
284aad4c-e58c-4f73-a38a-f3b1e374e76c
25
1
2
2
3
0
true
1
100
e06d8c4f-1103-4563-8fa7-a14f2e8b2e62
Dated
Dated
0
83c10054-eb06-4d7b-beba-998aa8e3be37
284aad4c-e58c-4f73-a38a-f3b1e374e76c
25
1
3
2
3
0
true
1
100
2484f3af-6bc8-4856-81d9-fe41c5cae732
Timed
Timed
0
83c10054-eb06-4d7b-beba-998aa8e3be37
284aad4c-e58c-4f73-a38a-f3b1e374e76c
25
1
4
2
3
0
true
1
100
b173c994-1cf7-4252-8dd9-a7b1485dca77
Verbal orders signed within 48 hours of order being given
VO signed w/in 48hrs
0
83c10054-eb06-4d7b-beba-998aa8e3be37
83c10054-eb06-4d7b-beba-998aa8e3be37
25
1
5
1
3
0
true
1
100
2f69f1ae-c800-40d5-8a27-eb17e0b22626
Evidence of “Read back” of verbal orders and critical test results/values (write down and read back)
Evidence of “Read back”
0
83c10054-eb06-4d7b-beba-998aa8e3be37
83c10054-eb06-4d7b-beba-998aa8e3be37
25
1
6
1
3
0
true
1
100
056ecee2-27c8-4a18-b4a1-2c933bcfe423
Restraints
Restraints
0
83c10054-eb06-4d7b-beba-998aa8e3be37
83c10054-eb06-4d7b-beba-998aa8e3be37
25
1
7
1
3
2
true
3
100
b15f533f-2c57-4b38-8740-cba7ee501706
Order for each day in restraint
Order ea day in restraint
0
83c10054-eb06-4d7b-beba-998aa8e3be37
056ecee2-27c8-4a18-b4a1-2c933bcfe423
25
1
8
2
3
0
true
3
100
379d995b-0c0b-4e82-b388-5d78bfe532dd
Reason documented
Reason documented
0
83c10054-eb06-4d7b-beba-998aa8e3be37
056ecee2-27c8-4a18-b4a1-2c933bcfe423
25
1
9
2
3
0
true
3
100
07def5ca-c2a0-4366-82d8-5212a8a28927
Alternatives considered
Alternatives considered
0
83c10054-eb06-4d7b-beba-998aa8e3be37
056ecee2-27c8-4a18-b4a1-2c933bcfe423
25
1
10
2
3
0
true
3
100
24d5c81f-2f52-4f50-bc1f-fe12b4100e1f
Monitoring appropriately documented
Monitoring documented
0
83c10054-eb06-4d7b-beba-998aa8e3be37
056ecee2-27c8-4a18-b4a1-2c933bcfe423
25
1
11
2
3
0
true
3
100
a5164af7-e7b3-4977-bcbc-d7dec5840ede
IMFORMATION MANAGEMENT
Information Management
0
a5164af7-e7b3-4977-bcbc-d7dec5840ede
a5164af7-e7b3-4977-bcbc-d7dec5840ede
26
2
0
0
3
2
true
1
100
1b9284a2-4e29-425b-9295-8ffb812b1f80
Check for legibility/readability in records
Check legibility/readab
0
a5164af7-e7b3-4977-bcbc-d7dec5840ede
a5164af7-e7b3-4977-bcbc-d7dec5840ede
26
2
1
1
3
0
true
1
100
64397952-5d84-4fe2-95e7-85a62dea0c09
Medical records secure from unauthorized access, computer screens secure
Medical records secure
0
a5164af7-e7b3-4977-bcbc-d7dec5840ede
a5164af7-e7b3-4977-bcbc-d7dec5840ede
26
2
2
1
3
0
true
1
100
32d56497-0eb7-4fb2-afc0-0d46d1dd3f8c
No computer passwords visible
No passwords visible
0
a5164af7-e7b3-4977-bcbc-d7dec5840ede
a5164af7-e7b3-4977-bcbc-d7dec5840ede
26
2
3
1
3
0
true
1
100
d2d50c3e-a848-42f5-96f2-a884c851ac5d
Privacy and confidentiality of patient info evident
Confidentiality evident
0
a5164af7-e7b3-4977-bcbc-d7dec5840ede
a5164af7-e7b3-4977-bcbc-d7dec5840ede
26
2
4
1
3
0
true
1
100
6898c982-2154-463b-9aa3-4c700b4e7349
MEDICATION MANAGEMENT
Medication Management
0
6898c982-2154-463b-9aa3-4c700b4e7349
6898c982-2154-463b-9aa3-4c700b4e7349
27
3
0
0
3
2
true
1
100
30fef11b-194d-41e1-99ac-3bcbc7069e71
PRN meds document indication or symptom
PRN meds document symptom
0
6898c982-2154-463b-9aa3-4c700b4e7349
6898c982-2154-463b-9aa3-4c700b4e7349
27
3
1
1
3
0
true
1
100
9358ffe6-2253-417d-a002-17646f929c00
Range orders document dose or interval
Range orders doc dose
0
6898c982-2154-463b-9aa3-4c700b4e7349
6898c982-2154-463b-9aa3-4c700b4e7349
27
3
2
1
3
0
true
1
100
7f9dfb3c-9619-454d-bfb5-e911649efdfa
Medication orders are:
Medication orders are:
0
6898c982-2154-463b-9aa3-4c700b4e7349
6898c982-2154-463b-9aa3-4c700b4e7349
27
3
3
1
3
2
true
1
100
92cedb01-641d-4668-8a3c-cb08bea9bf2a
Legible
Legible
0
6898c982-2154-463b-9aa3-4c700b4e7349
7f9dfb3c-9619-454d-bfb5-e911649efdfa
27
3
4
2
3
0
true
1
100
f51b0663-a4b0-4a07-a053-aa4cc419e0dd
Signed
Signed
0
6898c982-2154-463b-9aa3-4c700b4e7349
7f9dfb3c-9619-454d-bfb5-e911649efdfa
27
3
5
2
3
0
true
1
100
9a53fe2c-5032-458d-bdd3-a84dcbe4fe5b
Timed
Timed
0
6898c982-2154-463b-9aa3-4c700b4e7349
7f9dfb3c-9619-454d-bfb5-e911649efdfa
27
3
6
2
3
0
true
1
100
84ef78d5-6f13-48f2-bec4-2663a8ba7633
Dated
Dated
0
6898c982-2154-463b-9aa3-4c700b4e7349
7f9dfb3c-9619-454d-bfb5-e911649efdfa
27
3
7
2
3
0
true
1
100
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
PATIENT SAFETY/NPSGs
Patient Safety/NPSGs
0
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
28
4
0
0
3
2
true
1
100
9964667b-2f09-45e9-9273-bc639384b735
For verbal or telephone orders or for telephone reporting of critical test result by having the person receiving the information record and “read-back” the complete order or test result.
VO read back test result
0
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
28
4
1
1
3
0
true
1
100
0c2bd082-8292-488d-9693-a6efed08c086
No "do not use abbreviations" in the medical record
No do not use abbre in MR
0
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
28
4
2
1
3
0
true
1
100
fa6bc5c5-7a06-4731-b733-99b5573184cf
Measure, assess, and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results, values and medications.
Measure, assess, action
0
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
28
4
3
1
3
0
true
1
100
943fca74-6f98-43bc-8746-2b387788d8f6
Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions. (Check for documentation if required by hospital policy.)
Standardized approach
0
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
28
4
4
1
3
0
true
1
100
9db161c1-c05e-40f5-9a58-db382102a516
The organization identifies patients at risk for suicide. This is documented in the medical record.
Identify risk for suicide
0
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
6d75da7e-d7b1-4729-ac9b-7bbc26796dd5
28
4
5
1
3
0
true
1
100
d726e3b7-3a28-48ff-b52c-778b2ff47aac
MEDICATION RECONCILIATION
Medication Reconciliation
0
d726e3b7-3a28-48ff-b52c-778b2ff47aac
d726e3b7-3a28-48ff-b52c-778b2ff47aac
29
5
0
0
3
2
true
1
100
40e4f5cc-6ec8-400f-92f4-3d65bcafd4ff
Obtain and document the current home medication list. There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.
Obtain & document meds
0
d726e3b7-3a28-48ff-b52c-778b2ff47aac
d726e3b7-3a28-48ff-b52c-778b2ff47aac
29
5
1
1
3
0
true
1
100
7858551f-6669-45f1-a143-d05c79d6fac0
Compare the patient`s current medications with those ordered during treatment.
Compare pt current meds
0
d726e3b7-3a28-48ff-b52c-778b2ff47aac
d726e3b7-3a28-48ff-b52c-778b2ff47aac
29
5
2
1
3
0
true
1
100
b5508d3e-5b9a-435e-af6a-7743f3b71c67
Provide to the patient and next care giver (and document) a list of home medication and new medications ordered at discharge.
Doc list of home meds
0
d726e3b7-3a28-48ff-b52c-778b2ff47aac
d726e3b7-3a28-48ff-b52c-778b2ff47aac
29
5
3
1
3
0
true
1
100
c074d2d5-5781-47d6-94d1-5b05f90ce0bb
UNIVERSAL PROTOCOL
Universal Protocol
0
c074d2d5-5781-47d6-94d1-5b05f90ce0bb
c074d2d5-5781-47d6-94d1-5b05f90ce0bb
30
6
0
0
3
2
true
1
100
f638da12-505f-4fc8-a8b6-e45609c3c44b
Document a pre-operative verification process.
Pre-operative verifica
0
c074d2d5-5781-47d6-94d1-5b05f90ce0bb
c074d2d5-5781-47d6-94d1-5b05f90ce0bb
30
6
1
1
3
0
true
1
100
911cd549-4a37-4426-b3f9-0f42f07342da
Document a "time out" immediately before starting the procedure.
Document "time out" immed
0
c074d2d5-5781-47d6-94d1-5b05f90ce0bb
c074d2d5-5781-47d6-94d1-5b05f90ce0bb
30
6
2
1
3
0
true
1
100
82a4a7e9-cd81-4506-914a-60857f32d7b1
RIGHTS AND ETHICS
Rights and Ethics
0
82a4a7e9-cd81-4506-914a-60857f32d7b1
82a4a7e9-cd81-4506-914a-60857f32d7b1
31
7
0
0
3
2
true
1
100
7b8f8690-af93-4f97-aed0-d716134b16fc
Advance directives documented
Advance directive doc
0
82a4a7e9-cd81-4506-914a-60857f32d7b1
82a4a7e9-cd81-4506-914a-60857f32d7b1
31
7
1
1
3
0
true
1
100
9fc951f5-f64a-497c-87f6-099833a647c9
Patient wishes on chart
Patient wishes on chart
0
82a4a7e9-cd81-4506-914a-60857f32d7b1
82a4a7e9-cd81-4506-914a-60857f32d7b1
31
7
2
1
3
0
true
1
100
d8f0b6cc-2369-4749-95bc-fc399bc830d7
Consents
Consents
0
82a4a7e9-cd81-4506-914a-60857f32d7b1
82a4a7e9-cd81-4506-914a-60857f32d7b1
31
7
3
1
3
2
true
1
100
850f1cab-9e56-4f83-ab92-f11d1a2f86e9
Signed
Signed
0
82a4a7e9-cd81-4506-914a-60857f32d7b1
d8f0b6cc-2369-4749-95bc-fc399bc830d7
31
7
4
2
3
0
true
1
100
8fda8d83-cb24-483d-84aa-aca0d442e916
Dated
Dated
0
82a4a7e9-cd81-4506-914a-60857f32d7b1
d8f0b6cc-2369-4749-95bc-fc399bc830d7
31
7
5
2
3
0
true
1
100
12c6dce4-584e-4ac0-ba6b-4a9dcbd401d9
Timed
Timed
0
82a4a7e9-cd81-4506-914a-60857f32d7b1
d8f0b6cc-2369-4749-95bc-fc399bc830d7
31
7
6
2
3
0
true
1
100
622dd15f-ce05-4796-b685-f15366555509
Informed decision-making
Informed decision-making
0
82a4a7e9-cd81-4506-914a-60857f32d7b1
82a4a7e9-cd81-4506-914a-60857f32d7b1
31
7
7
1
3
0
true
1
100
eba15b12-6485-48e5-8e4f-f157612d2bef
End of life care documented
End of life care document
0
82a4a7e9-cd81-4506-914a-60857f32d7b1
82a4a7e9-cd81-4506-914a-60857f32d7b1
31
7
8
1
3
0
true
1
100