Tracer Record Review - Outpatient Only updated: 3/21/2016 Data Definition Tool The Tracer Packet is to be completed in each outpatient area 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. Outpatient Units: Monitor at least 1 patient record per Standard month using the Tracer Record Review Outpatient Tool. ADMISSION 1 Medical Record Number: 2 Functional screen complete PC.01.02.01 EP 4; PC.01.02.03 EP 8 3 If functional screen positive, plans for follow-up PC.01.02.01 documented EP 4 Location YES VMG Clinic Intake Form Activities of Daily Living section completed. VMG Assesssment & Follow-up for Positive Intake Screen in PT, OT, ST sections. Positive screen follow up documented on form; NA=negative screen or preexisting condition (i.e., blind, cerebral palsy, or ADHD) 4 Nutritional screen complete PC.01.02.01, EP VMG Clinic Intake 4; PC.01.02.03 Form EP 7 5 If nutritional screen positive, plans for follow-up documented. PC. 01.02.01 EP VMG Assesssment & Positive screen follow up 4; Follow-up for Postive documented on form ; or Intake Screen negative screen = NA 6 Pain screen complete PC.01.02.07 EP 1 & 2 VMG Clinic Intake Form Nutritional screen completed. Pain screen completed 7 If pain screen positive, plans for follow-up documented PC.01.02.01 EP 23; PC.01.02.07 EP 3 8 Abuse screen complete PC.01.02.09 EP 4 9 If abuse screen positive, plans for follow-up PC.01.02.09 documented EP5, 6, & 7 VMG Assesssment & Positive screen (option C and Follow-up for Postive >3) follow up documented on Intake Screen. form; or negative screen = NA VMG Clinic Intake Form VMG Assesssment & Follow-up for Postive Intake Screen. Social Environment screen completed. Positive screen follow up documented on form; or negative screen = NA 10 Falls screen complete PC.01.02.08 EP 1 11 If falls screen positive, plans for follow-up documented PC.01.02.08 EP 2 12 Learning needs/education screen complete PC.02.03.01 EP 1, 4 & 5 13 If education screen positive, plans for follow-up PC.02.03.01 documented EP 10 VMG Assessment & Follow-up. VMG Assessment & Follow-up. VMG Clinic Intake Form. VMG Assessment & Follow-up 14 Preferred language for discussing health care documented. PC.02.01.21 EP 1 VMG Clinic Intake Form and the Starpanel outpatient white board Falls screen completed for pts >/= 65 yrs. Positive screen follow-up documented on form. Educational screen completed. Positive screen follow-up documented on form or negative screen = NA Documented RC.02.01.07 EP 2 RC.02.01.07 EP 3 StarPanel - click on Problem list. StarPanel - click on Problem list. PC.02.03.01 VMG Assesssment & All teaching fields are Follow-up for Positive completed as appropriate. Intake Screen PROBLEM LIST (OP Only) 15 Complete (diagnoses, procedures, allergies, meds) 16 Updated at every physician visit PATIENT EDUCATION 17 All "teaching" fields complete, as appropriate (excluding pain management) All component fields are completed in StarPanel. Date of problem list matches most current physician visit. 18 Documentation by all disciplines, involved in the patient's care, treatment, or services. PC.02.03.01 EP 5 Same as above. Paper and individual discipline notes Signature(s) & initials are present for appropriate disciplines. MEDICATION ADMINISTRATION 19 "Do Not Use" Abbreviations are NOT found in the MR on date of review? IM.02.02.01 EP 3 No " Do Not Use" abbreviations are found in the medical record on the date of review. 20 Supporting documentation (diagnosis, condition, or indication) for every order for "current" medications. MM.04.01.01 EP 9 All entries in the medical record on date of review including medication orders, problem list, flowsheets, progress notes,etc. Physician orders, H&P, progress notes 21 Order present for each medication administered. RC.02.01.01 EP 2 22 Are orders for PRN medications specific such that there is no therapeutic duplicatoin (multiple options for a specific indication? StarPanel: medication administration; progress notes Medications list Diagnosis, condition or indications for use are documented. Order present. 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). OPERATIVE & OTHER PROCEDURES 23 RI.01.03.01 Consent form present and signed, dated and timed. EP 13 24 Type of sedation/anesthesia included on consent form. RI.01.03.01 EP 13 Consent Form Consent form/ Anesthesia Care Record Form completed, signed, dated, and timed. Type of sedation/anesthesia consent is documented 25 Provider history and physical (H&P) completed and documented prior to procedure? PC.01.02.03 EP5; H& P form H&P on record prior to procedure/surgery and w/in appropriate timeframes: PC.03.01.03 EP 4 On sedation form 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.) 26 Pre-procedural education documented before operative or high-risk procedures or before moderate or deep sedation or anesthesia. 27 Patient's conditionis re-evaluated before administering PC.03.01.03 moderate or deep sedation. EP 8 Sedation & Analgesia ASA class and Pre-Sedation Record, Anesthesia status completed for record moderate or deep sedation. 28 Pre-Procedure Checklist is completed? Pre-procedure checklist Area specific documentation systems. Sedation/Analgesia form 29 "Time Out" documented before procedure. UP.01.01.01 EP 2 UP.01.03.01 EP 5 All fields completed, as appropriate. Completed including date and time. 30 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. 31 The Operative/Procedural report is dictated or electronically entered in the pt record within 24 hrs of the procedure and includes: 1. Patient’s name and unit number; 2. 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; 7. Specimen(s) removed, if any; 8. Any laboratory or diagnostic procedure ordered; 9. Complications, if any; 10. Condition of patient. Surgical / procedure Report 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. RC.02.01.03 EP 5 & 6 CMS.482.51.(b) 32 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. (Procedural Areas) 33 Discharge instructions form present and complete 34 Patients who receive sedation or anesthesia are discharged in the company of an individual who accepts responsibility for the patient. PC.03.01.07 EP 4 Discharge criteria documentation. Discharge criteria documenation PC.04.01.05 EP 8 PC.03.01.07 EP 6 Discharge instruction Form completed, dated, and form timed. On sedation form Documentation present.