Record Review Inpatient Only
3/21/2016
Data Definition Tool
The Tracer Packet is to be completed in each inpatient unit by the manager or designee on a monthly basis. It is suggested that the manager does not
complete a packet for his/her own area. Tracers are due on the last day of the month following the review (example: July Tracer due July 31).
Instructions: Indicate Yes, No, NA (Not Applicable)
for each question below.
Inpatient Units: Monitor at least 1 patient record per
month using the Tracer Record Review Inpatient Tool.
Standard
ADMISSION
1 Medical Record Number:
PC.01.02.03
2 Initial nursing history completed within 24 hours of
EP 2 & 6
admission
3 Provider history and physical (H&P) completed and
documented.
(May use previous H&P documented within 30 days
prior or 24 hours after admission or registration that
includes an update. The update includes an
examination and any changes to the patient's
condition.)
PC.01.02.03
EP 4 & 5
Location
YES
HED: 1) Admission History tab (nurseries); 2)
StarPanel starform for all Inpt. units that document in
HED except nurseries; 3)StarPanel PDF of VPIMS
Periop Nursing documentation for Periop staff; 4)
StarPanel PDF for Cath Lab Nursing documentation;
5)paper record Admission /History/ Discharge form if
completed during downtime or by an area where none
of these electronic options is available.
All components completed &
signed by RN w/in timeframe
as indicated on (1) Time of
Medipac transaction to admit;
(2) Time order written in
CPOE; or (3) Time on Nursing
Admission History
H& P form or Star Panel
H&P time on record w/in
appropriate timeframes which
are up to 24 hrs including:
Previous H&P documented
within 30 days prior or 24
hours after admission or
registration that includes an
update. The update includes
an examination and any
changes to the patient's
condition.
4 Nursing physical assessment completed on
admission?
PC.01.02.01
EP 4
PC.01.02.03
EP 6
Assessment/Intervention tab age appropriate
First assessment completed
w/in 8 hrs of admit time as
indicated on (1) Time of
Medipac transaction to admit;
(2) Time order written in
CPOE; or (3) Time on Nursing
Admission History
5 Functional screen complete?
PC.01.02.01
EP 4;
PC.01.02.03
EP 8
Functional Screen complete
within 24 hours.
6 If functional screen positive, plans for follow-up
documented
PC.01.02.01
EP 4
1) Admission History StarForm in StarPanel for units
that chart in HED (nurseries do not complete
Functional Screen on newborns); 2) paper admission
history if completed in area that does not document in
HED
Admission History
7 Nutritional screen complete
PC.01.02.01
EP 4;
PC.01.02.03
EP 7
PC.01.02.07
EP1 & 2
PC.01.02.01
EP 23;
PC.01.02.07
EP 3
PC.01.02.09
EP 4
Admission History/Discharge Plan
Nutritional screen completed
within 8 hours
Nursing Assessment in HED
Pain screen completed within
8 hours
Positive screen follow up of
initial screen completed or
negative screen = NA
11 If abuse screen positive, plans for follow-up
documented
PC.01.02.09
EP 5, 6, & 7
Admission History age appropriate tab
12 Suicide Risk screen completed (including the
environment) for patients with primary diagnosis of
emotional or behavioral disorders?
NPSG.
15.01.01.01
EP 1
VPH documents suicide risk screen in HED. In other
areas, it's part of safety assessment documented in
age appropriate assessment interventions tab.
8 Pain screen complete
9 If pain screen positive, plans for follow-up
documented
10 Abuse screen complete
(Children's 8C when applicable and all VPH)
NPSG.
13 If Suicide Risk screen positive, follow-up includes
provider assessment and environmental assessment. 15.01.01.01
EP 1
PC.02.03.01
14 Learning needs/education screen complete
NA is inappropriate answer for inpatients.
EP 1, 4 & 5
PC.02.01.21
15 Preferred language for discussing health care
documented.
EP 1
Nursing Assessment in HED
Admission History
VPH - in suicide screen section. Other HED areas - in
Safety interventions. Provider assessment would be in
StarPanel.
Admission History tab (IP)
In admission history
Positive screen & provider
contacted, MD notified
documented as free text note.
NA=negative screen OR preexisting condition (i.e., blind,
cerebral palsy, or ADHD)
Social Work screen
completed;
NA is inappropriate answer for
inpatients
Positive screen & check in
"social work ordered" box or
negative screen = NA
Patients with emotional or
behavioral disorder diagnosis
has completed assessment.
Nursing environmental
assessment and provider
assessment is documented.
Learning needs completed
within 8 hours
Documented
16 Discharge planning initiated within 24 hours of
admission
Alcohol and Substance Abuse Disorders
17 Assessment includes the following:
* patient's religion and spiritual beliefs, values and
preferences;
* living situation;
* leisure and recreational activities;
* military service history;
* peer group;
* social factors;
* ethnic & cultural factors;
* financial status;
* vocational or educational background;
* legal history;
* communication skills.
18 Assessment includes the following:
* history of physical or sexual abuse as either the
abuser or the abused;
* Sexual history and identification;
* Childhood history;
* Emotional and health issues:
* Visual - motor function;
* Self-care.
19 Assessment includes the patient's family
circumstances including the composition of the family
group and the need for their participation in the
patient's care.
Emotional and Behavioral Disorders
20 Assessment includes the following:
* patient's religion and spiritual beliefs, values and
preferences;
* living situation;
* leisure and recreational activities;
* military service history;
* peer group;
* social factors;
* ethnic & cultural factors;
* financial status;
* vocational or educational background;
* legal history;
* communication skills.
PC.04.01.03
EP 1
Plan of Care
Plan initiated w/in timeframe
or Case Management &
Socical Work screen
negataive
PC.01.02.11
EP 5
VPH Psychosocial Assessment & VPH Nursing
Assessment documented and
Admission History & Psychiatric Admission Evaluation contains all elements.
(starpanel) and/or Crisis Assessment (paper record)
PC.01.02.11
EP 6
VPH Psychosocial Assessment & VPH Nursing
Assessment documented and
Admission History & Psychiatric Admission Evaluation contains all elements.
(starpanel) and/or Crisis Assessment (paper record)
PC.01.02.11
EP 7
VPH Pscyhosocial Assessment and Psychiatric
Admission Evaluation (Starpanel)
PC.01.02.13
EP 3
VPH Psychosocial Assessment & VPH Nursing
Assessment documented and
Admission History & Psychiatric Admission Evaluation contains all elements.
(starpanel) and/or Crisis Assessment (paper record)
Assessment documented and
contains all elements.
21 Assessment includes the following:
* history of physical or sexual abuse as either the
abuser or the abused;
* Sexual history;
* Childhood history;
* Emotional and healthcare issues:
* Visual - motor function;
* Self-care.
22 Assessment includes the following:
* patient's family circumstances including the
composition of the family group;
*Community Resources currently used by the patient;
and
*The need for their participation in the patient's care.
PC.01.02.13
EP4
VPH Psychosocial Assessment & VPH Nursing
Assessment documented and
Admission History & Psychiatric Admission Evaluation contains all elements.
(starpanel) and/or Crisis Assessment (paper record)
PC.01.02.13
EP 5
VPH Pscyhosocial Assessment and Psychiatric
Admission Evaluation (Starpanel)
Assessment documented and
contains all elements.
Psychiatric Admission Evaluation (Starpanel)
Assessment documented and
contains all elements.
Advance Directives Progress Notes and HED
Admission / History Extended Data (both completed)
Both Advance Directives
Progress Notes form and HED
data completed to be Yes.
Clear plastic advance directive sleeve at the front of
the chart (1st item) or on Advance Directives Progress
Notes or physician progress notes or scanned in star
panel under legal documents and in HED Adm/History
extended data
Choice of:
Copy present or directive
signed by physician OR
- Copy in STAR Panel from
previous admission under
"ALL" and then "legal
Documents" OR
- Answer
"NA" if patient has no
Advance Directive
PC.01.02.13
23 Assessment includes the following:
* Psychiatric evaluation;
EP6
* Pscyhological assessments including intellectual
projective neuropsychological and personality testing;
* Complete neurological examination, when indicated.
ADVANCE DIRECTIVES
(IP Only)
24 Advance Directives Progress Notes (MC# 4137)
signed and completed?
25 Copy in chart or substance of directive in physician's
progress notes or on Advance Directives Progress
Notes (MC#4137)
RC.02.01.01
EP 4
RI.01.05.01
EP 9
RI.01.05.01
EP 9 & 11
NURSING ASSESSMENT (IP Only)
26 Physical assessment per shift or unit standard?
27 Each patient is reassessed as necessary based on
his or her plan for care or changes in his or her
condition.
PC.01.02.01
EP 23;
PC.01.02.03
EP 3
Assessment/Intervention age appropriate tab
PC.01.02.03
EP 3
Assessment/Intervention age appropriate tab
Date, nurse signatuare & title,
time and initials are
documented and check mark
placed beside "Standards
Met" or "Except as Noted" for
each section.
Date, nurse signatuare & title,
time and initials are
documented and check mark
placed beside "Standards
Met" or "Except as Noted" for
each section.
Time, Date, Pain
Score/indicators are
documented
28 Pain assessment at least every shift; when there is a PC.01.02.07
change in patient condition or primary caregiver.
EP 1
Assessment/ Intervention age appropriate or Pain tab
29 Interventions r/t pain management are documented
PC.01.02.07
EP 4
Assessment/Intervention age appropriate tab or Pain
tab
Interventions, post time, relief,
initials are documented.
30 Pain is reassessed after administration of pain
med/comfort measures
PC.01.02.07
EP 3
Assessment/Intervention age appropriate tab or pain
tab and/or Controlled Drug Record
Interventions, date time, pain
score, and initials are
documented within 2 hrs of
intervention. Exception:
PCA or continuous infusion IV
analgesia assessment
documented every 4 hrs.
HED Education Tab
32 All "teaching/education" fields complete, as
appropriate (excluding pain management)
PC.02.03.01
EP 10
PC.02.03.01
EP 10
33 Documentation by all disciplines involved in the
patient's care, treatment or services.
PC.02.03.01
EP 5
PATIENT EDUCATION
31 Pain management addressed, as appropriate
MEDICATION ADMINISTRATION
34 "Do Not Use" Abbreviations are NOT found in the MR IM.02.02.01
on date of review?
EP 3
35 Supporting documentation (diagnosis, condition, or
indication for use) exists for every order for "current"
medications.
MM.04.01.01
EP 9
All teaching fields specific to
pain are completed.
Education Record "other" or HED Education Tab
All teaching fields are
appropriately completed
except pain management
teaching.
Same as above. Paper and individual discipline notes; Signature(s) & initials are
Electronic documentation available via OPC
present for appropriate
Assessment Section.
disciplines.
All entries in the medical record on date of review
including medication orders, MAR, problem list,
flowsheets, progress notes,etc.
Physician orders, H&P, progress notes
No " Do Not Use"
abbreviations are found in the
medical record on the date of
review.
Diagnosis, condition or
indications for use are
documented anywhere in the
medical record including the
H&P
36 Are orders for PRN medications specific such that
there is no therapeutic duplicatoin (multiple options
for a specific indication?
Medications list
Review patient's current PRN
medication orders for
therapeutic duplication. There
should not be two orders that
have the same instructions for
when to administer (e.g., prn
pain, prn nausea, prn for
agitation).
DISCHARGE (IP Only)
37 Discharge plan reviewed every 24 hours.
PC.04.01.03
EP 1
Plan of Care tab
38 Discharge instructions completed upon discharge.
PC.04.01.05
EP 8
39 For patients admitted with primary diagnosis of
emotional or behavioral disorders, discharge
instructions include suicide prevention information
such as crisis hot line number.
OPERATIVE & OTHER PROCEDURES
40 Consent form present and signed, dated and timed?
NPSG.
15.01.01.01
EP 3
1) Discharge Process tool document saved to
StarPanel. 2) Paper Discharge Instructions sheet
scanned into StarPanel if pt. discharged during
HEO/Wiz downtime or Discharge Process tool not
used.
WIZ or paper Patient Discharge Instructions or
discharge letters per speciality
Check box on Plan of
Care/Discharge Plan tab for
"done"
Discharge letter complete and
in StarPanel
Discharge instructions
includes suicide prevention
information
RI.01.03.01
EP 13
PC.01.02.03
EP 5
Consent Form
H& P form
consent form present and
signed, dated and timed
H&P on record prior to
procedure/ surgery and w/in
appropriate timeframes:
42 Pre-procedural education documented before
operative or high-risk procedures or before moderate
or deep sedation or anesthesia.
43 Patient's condition is re-evaluated before
administering moderate or deep sedation or
anesthesia.
PC.03.01.03
EP 4
Preop Nursing Record (PDF in Starpanel)
Documented
PC.03.01.03
EP 8
Sedation & Analgesia Record, Anesthesia record
ASA class and Pre-Sedation
Status completed for
moderate or deep sedation.
For OR area Anesthesia Care
Record ASA score prior to
induction completed.
44 Pre-procedure checklist is completed.
UP 01.01.01
EP 2
UP 01.03.01
EP 5
Pre-procedure checklist
All fields completed, as
appropriate.
Completed including date and
time.
41 Provider history and physical (H&P) completed and
documented prior to procedure?
(May use previous H&P documented within 30 days
prior or 24 hours after admission or registration that
includles an update. The update includes an
examination and any changes to the patient's
condition.)
45 "Time Out" documented before procedure.
Area Specific documentation systems. Sedation/
Analgesia form.
46 Immediate Post Operative/procedural Note is present RC.02.01.03
EP 7
and includes the following:
1. Name of surgeon, proceduralist and assistants;
2. Procedure(s) performed and description of the
procedure;
3. Findings;
4. Estimated blood loss;
5. Specimen(s) removed, if any.
6. Postoperative diagnosis.
Post surgical progress notes
All elements are documented
in the record before the
patient moves to the next
level of care irregardless of
physical location.
NA=Operative/Procedural
report completed before the
patient is transferred to the
next level of care or if the
proceduralist accompanies
the patient from the procedure
room to the next level of care,
the note can be written in that
unit or area of care.
RC.02.01.03
Surgical / procedure Report
47 The Operative/Procedural report is dictated or
electronically entered in the pt record within 24 hrs of EP 5, 6 & 7
the procedure and includes:
1. Patient’s name and medical record number;
CMS.482.51.(b)
2. Name and date of procedure;
3. Name of surgeon, proceduralists and assistants;
4. Pre-operative diagnosis,
5. Postoperative diagnosis;
6. Anesthetic agent used;
7. Description of the techniques and procedure;
8. Description of the findings;
9. Estimated blood loss;
10. Specimen(s) removed, if any;
11. Any laboratory or diagnostic procedure ordered;
12. Complications, if any;
13. Condition of patient.
All elements are documented
in the report and dictated or
electronically entered within
24 hours of the procedure.
The attending physician has
signed the report within 14
days of the procedure.
48 For operative or high-risk procedures and/or the
administration of moderate or deep sedation or
anesthesia, patients are discharged from recovery
area by LIP or by criteria. (Operative/Procedural
Areas)
Discharge criteria
documented
PC.03.01.07
EP 4
Discharge Criteria documentation