Closed Medical Record Review

Sub-Std
Sub-Standard

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

AVG
(10)
No.

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)
The hospital implements a policy and procedure that defines the assessment process and its scope and content for
PC.6.2
all categories of patients (adults, geriatrics, pediatrics, pregnant women, trauma patients and others).
The hospital implements a policy and procedure that defines the assessment process and its scope and content for
PC.6.3
all disciplines (physicians, nurses, physiotherapists, social service and others).
PC.6.4 The policy defines the staff categories qualified by license, certification, and experience to assess patients.
PC.8.1 The hospital has criteria to identify patients requiring discharge planning before or upon admission
The hospital implements a policy that defines the time frame for completing the medical, nursing, and other
PC.9.1
assessments required for different care settings and services.
Each patient undergoes an initial medical assessment that includes a health history and physical examination,
covering the following:
PC.10.1 PC.10.1.1 Main complaint.
PC.10.1.2 Details of the present illness.
PC.10.1.3 Systems review.
PC.10.1.4 Past history including previous admissions and surgeries.
PC.10.1.5 Allergies and prior adverse drug reactions.
PC.10.1.6 Drug history.
PC.10.1.7 Family history.
PC.10.1.8 Psycho-social history.
PC.10.1.9 Economic factors.
PC.10.1.10 Pain (screening followed by assessment if required).
PC.10.1.11 Risk for fall (screening followed by assessment if required).
PC.10.1.12 Physical status and functionality (screening followed by assessment if required).
PC.10.1.13 Complete physical examination.
PC.10.1.14 Diagnostic test(s) as indicated by the patient’s condition.
PC.10.1.15 Need for additional or specialized assessment as indicated by the patient’s
PC.10.1.16 Need for discharge planning as indicated by the patient’s condition.
PC.10.1.17 Provisional diagnosis.
Sub-Std
Sub-Standard

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

AVG
(10)
No.

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)
Medical assessment is performed by the most responsible physician or a member of the team who is qualified by
PC.10.3 license, certification, and experience.
PC.10.6 The medical assessment is documented in the patient’s medical record.
All patients are reassessed at appropriate intervals to determine:
PC.17.1.1 Response to treatment.
PC.17.1
PC.17.1.2 Compliance with treatment.
PC.17.1.3 Complications and side effects.
PC.17.1.4 Plan for continued treatment or completion of treatment.
Nursing reassessment must be performed on every shift with a frequency dictated by the patient’s condition,
PC.17.3
response to treatment, and physician’s order.
The hospital defines situations where re-assessments are performed more infrequently (e.g., long stay patients
PC.17.5
mainly requiring a nursing care).
When required, the hospital provides referral and transfer services to other facility that can provide palliative care(e.g., bed or
PC.24.5
resources availability).
When applicable, the hospital provides or arrange for a nursing home care (e.g., inability to refer, or patient/family
PC.24.6
wish).
Only physicians order blood and in accordance with a policy clarifying when blood and blood products may be
PC.25.2
ordered.
The physician obtains informed consent for transfusion of blood and blood products. Elements of patient consentinclude:

PC.25.3 PC.25.3.1 Description of the transfusion process.

PC.25.3.2 Identification of the risks and benefits of the transfusion.
PC.25.3.3 Identification of alternatives including the consequences of refusing the treatment.
PC.25.3.4 Giving the opportunity to ask questions.
PC.25.3.5 Giving the right to accept or refuse the transfusion.
Two staff members verify the patient’s identity prior to blood drawing for cross match and prior to theadministration of
PC.25.4
blood.
PC.25.6 Blood is transfused according to accepted transfusion practices from recognized professional organizations.
PC.25.8 Patients receiving blood are closely monitored.
PC.25.9 Transfusion reactions are reported and analyzed for preventive and corrective actions.
Two staff members verify the patient’s identity prior to blood drawing for cross match and prior to theadministration of
PC.25.4
blood.
Sub-Std

MRN(2)

MRN(3)

MRN(4)

MRN(5)

MRN(6)

MRN(7)

MRN(8)

MRN(9)
No. Sub-Standard

MRN

MRN

AVG
(10)
PC.33.3 Activities of the rapid response teams are documented.
PC.38.1 The patient and the family are involved in the discharge process with clear follow up instructions.
PC.38.2 Discharge is based on the patient’s condition and relevant policies or criteria.
PC.38.3 Patients' needs after discharge are assessed as early in the care process as possible.
PC.38.4 The discharge process identifies the post-service needs and supports continuity of care after discharge.
PC.38.5 The post-service needs are communicated to relevant staff members.
PC.38.6 Staff members ensure coordination with various departments involved in the discharge process.
Whenever required, staff members ensure coordination with outside organizations and post-service providers as
PC.38.7
appropriate to the patient's needs.

PC.38.8 Staff members ensure that all patients’ needs are met prior to discharge.
Transfer is based on the patient's health needs for continuing care and the resources available for both referring
PC.39.2 and receiving organizations.

The most responsible physician determines the need for transfer, the most suitable time for transfer, resources required
PC.39.3 during transfer, and whether the receiving organization can meet the patient’s health and supportive
needs.

There is a written acceptance for transfer of responsibility for the patient's care by the receivingprovider/organization.
PC.39.5

The hospital communicates with all potential receiving organizations and necessary arrangements are made
PC.39.6
whenever applicable.

PC.40.1 The most responsible physician assesses the transportation needs of the patient according to his condition.
PC.40.2 Transportation needs of the patient are communicated to the relevant staff.
PC.40.4 The most responsible physician ensures that all patient’s health needs during transportation are met.
PC.40.5 Adequate equipment and supplies are available during transportation.
PC.40.6 A qualified staff member accompanies the patient during transportation.
PC.40.7 The patient is monitored as appropriate during transfer.
PC.40.8 Handover is completed to staff at the receiving organization
Sub-Std

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

AVG
Sub-Standard

(10)
(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)
No.
A summary of the patient's condition (e.g., a discharge summary) is sent with the patient to the receiving
organization. The summary includes:
PC.41.1.1 Reason for the patient’s admission.
PC.41.1.2 Patient diagnosis.
PC.41.1 Brief summary of hospitalization and services provided (therapies, consultations, procedures to
PC.41.1.3
date).
PC.41.1.4 Medication list and time of last dose(s) given.
PC.41.1.5 Patient condition and physical status at the time of transfer.
PC.41.1.6 Rationale for transfer.
PC.41.1.7 Results of the patient’s diagnostic investigations (e.g., laboratory and radiology).
PC.42.1 Whenever required, follow up appointments are arranged for the patient prior to discharge.
PC.42.3 The hospital provides a discharge summary for all inpatients upon discharge.
PC.42.4 A copy of the discharge summary is kept in the patient’s medical record.
PC.42.5 A copy of the discharge summary is given to the patient.
PC.42.7 The discharge summary is complete and typewritten.
The scope and content of the nursing assessment is defined in hospital policies and may include:
NR.10.2.1 History of the patient’s main complaint.
NR.10.2.2 Drug allergies.
NR.10.2.3 Physical condition.
NR.10.2 NR.10.2.4 Psychosocial status.
NR.10.2.5 Pain assessment.
NR.10.2.6 Nutritional Status.
NR.10.2.7 Discharge planning.
NR.10.2.8 Skin assessment.
NR.10.2.9 Fall risk assessment.
QM.14.5 Patients receive response when involved in significant incidents with documentation in the medical records.
QM.18.2 The process consists of three phases: verification, site marking, and time out.
A pre-procedure verification of the patient information is carried out including the patient’s identity, consent, full
QM.18.3
details of the procedure, laboratory tests and images, and any implant or prosthesis.
The surgical/procedural site is marked before conducting the surgery/procedure.
The site is marked especially in bilateral organs and multiple structures (e.g. fingers, toes, andspine).
QM.18.4.1
QM.18.4 QM.18.4.2 The site is marked by the individual who will perform the procedure.
QM.18.4.3 The patient is involved in the marking process.
QM.18.4.4 The marking method is consistent throughout the hospital.
QM.18.4.5 The mark is visible after the patient is prepped and draped.