Tracer Record Review - Periop Only 3-21-2016
Data Definition Tool
The Tracer Packet is to be completed in each Periop 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 is
IP = Inpatient
OP = Outpatient
Instructions: Indicate Yes, No, NA (Not Applicable)
for each question below.
Periop Units: Monitor at least 1 patient record per
month using the Tracer Record Review Periop Tool.
ADMISSION
1 Medical Record Number:
2 Initial nursing history completed within 24 hours of
admission [those that are admitted as Inpatient]
PC.01.02.03
EP 2 & 6
HED: Admission History tab
or paper record Admission
/History/ Discharge form
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
3 Provider history and physical (H&P) completed and
documented?
PC.01.02.03
EP 4 & 5
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.
PC.01.02.01
EP 4;
PC.01.02.03
EP 6
Assessment/Intervention tab
age appropriate
Standard
Location
(May use previous H&P documented within 30 days
prior or 24 hours after admission or registration that
includes an update. This update includes an
examination and any changes in the patient's
condition).
4 Nursing physical assessment completed on
admission?
YES
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
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(IP)
VMG Clinic Intake Form (OP)
Functional Screen complete within
24 hours(IP).
Activities of Daily Living Section
completed (OP)
6 If functional screen positive, plans for follow-up
documented
PC.01.02.01
EP4;
Admission History tab (IP);
VMG Assesssment & Followup for Positive Intake Screen
(OP) in PT, OT, ST sections.
7 Nutritional screen complete
PC.01.02.01
EP 4;
PC.01.02.03
EP 7
PC.01.02.01
EP 4;
PC.01.02.03
EP 7
PC.01.02.07
EP 1 & 2
Admission History/Discharge
Plan (IP); VMG Clinic Intake
Form (OP)
Positive screen & provider
contacted, MD notified documented
as free text note (IP), Positive
Screen follow-up documented on
form (OP).
NA = negative screen or preexisting condition (i.e, blind,
Cerebral Palsy, or ADHD)
Nutritional screen 8 hours (IP)
Nutrition Screen completed (OP)
8 If nutritional screen positive, plans for follow-up
documented (OP Only)
9 Pain screen complete
10 If pain screen positive, plans for follow-up documented PC.01.02.01
EP 23;
PC.01.02.07
EP 3
VMG Assesssment & Followup for Postive Intake Screen
(OP)
(OP only) Positive screen follow up
documented on form ; or negative
screen = NA
Nursing Assessment in HED
(IP); VMG Clinic Intake Form
(OP)
Nursing Assessment in HED
(IP); VMG Assesssment &
Follow-up for Postive Intake
Screen (OP)
Pain screen completed within 8
hours (IP)
Pain screen completed (OP).
Positive screen (score ≥4) follow up
of section of initial screen
completed (IP); Positive screen
(Option 3 and score >3) follow up
documented on form (OP); or
negative screen = NA (IP, OP)
11 Abuse screen complete
PC.01.02.09
EP4
12 If abuse screen positive, plans for follow-up
documented
PC.01.02.09
EP 5, 6, & 7
13 Falls screen complete
PC.01.02.08
EP 1
14 If falls screen positive, plans for follow-up documented PC.01.02.08
EP 2
15 Preferred language for discussing health care
PC.02.01.21
documented.
EP 1
16 Learning needs/education screen complete
PC.02.03.01
EP 1, 4, & 5
17 If education screen positive, plans for follow-up
documented (OP only)
PC.02.03.01
EP 10
18 Discharge planning initiated within 24 hours of
admission (IP only)
PC.04.01.03
EP1
ADVANCE DIRECTIVES
(IP Only)
19 Advance Directives Progress Notes (MC#4137) signed RC.02.01.01
and completed
EP 4
RI.01.05.01
EP 9
Admission History age
appropriate tab (IP); VMG
Clinic Intake Form (OP)
Admission History age
appropriate tab (IP); VMG
Assesssment & Follow-up for
Postive Intake Screen (OP)
VMG Assessment & Followup.
VMG Assessment & Followup.
In admission history
Social Work screen completed (IP);
Social Environment screen
completed ( OP)
Positive screen & check in "social
work ordered" box (IP); positive
screen follow up documented on
form (OP); or negative screen = NA
(IP, OP)
Falls screen completed for pts >/=
65 yrs. (OP)
Positive screen follow-up
documented on form. (OP)
Documented
Learning needs completed within 8
Admission History tab (IP);
VMG Clinic Intake Form (OP) hours (IP); Educational screen
completed (OP)
VMG Assessment & Follow- Positive screen follow-up
documented on form or negative
up
screen = NA
Plan of Care
Plan initiated w/in timeframe or
Case Management & Socical Work
screen negataive
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.
20 Copy in chart or substance of directive in physician's
progress notes or on Advance Directives Progress
Notes (MC#4137)?
PLAN OF CARE (IP Only)
21 Perioperative Services Plan of Care is completed and
present in the patient record?
NURSING ASSESSMENT (IP Only)
22 Physical assessment per shift or unit standard
RI.01.05.01
EP 9 & 11
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.01.03.01
EP 1
VPIMS
Plan of Care completed
PC.01.02.01
EP 23;
PC.01.02.03
EP 3
Assessment/Intervention age
appropriate tab
24 Pain assessment at least every shift; when there is a
change in patient condition or primary caregiver.
PC.01.02.07
EP 1
Date, nurse signatuare & title, time
and initials are documented and
check mark placed beside
"Standards Met" or "Except as
Noted" for each section.
Assessment/Intervention age Date, nurse signatuare & title, time
and initials are documented and
appropriate tab
check mark placed beside
"Standards Met" or "Except as
Noted" for each section.
Assessment/ Intervention age Time, Date, Pain Score/indicators
appropriate or Pain tab
are documented
25 Interventions r/t pain management are documented
PC.01.02.07
EP 4
Assessment/Intervention age
appropriate tab or Pain tab
26 Pain is reassessed after administration of pain
med/comfort measures
PC.01.02.07
EP3
Assessment/Intervention age Interventions, date time, pain score,
appropriate tab or pain tab
and initials are documented within 2
and/or Controlled Drug Record hrs of intervention. Exception:
PCA or continuous infusion IV
analgesia assessment documented
every 4 hrs.
23 Each patient is reassessed as necessary based on his PC.01.02.03
or her plan for care or changes in his or her condition. EP3
Interventions, date, time, initials are
documented.
PATIENT EDUCATION
27 Pain management addressed, as appropriate (IP
only)
28 All "teaching/education" fields complete, as
appropriate (excluding pain management)
PC.02.03.01
EP 10
PC.02.03.01
EP 10
Education Record "other"
29 Documentation by all disciplines involved in the
patient's care, treatment, or services?
MEDICATION ADMINISTRATION
30 "Do Not Use" Abbreviations are NOT found in the MR
on date of service?
PC.02.03.01
EP 5
Same as above. Paper and
individual discipline notes
IM.02.02.01
EP 3
All entries in the medical
No " Do Not Use" abbreviations are
record on date of review
found in the medical record on the
including medication orders,
date of review.
MAR, problem list, flowsheets,
progress notes,etc.
31 Supporting documentation (diagnosis, condition, or
indication for use) for every order for "current"
medications.
MM.04.01.01
EP 9
Physician orders, H&P,
progress notes
RI.01.03.01
EP 13
RI.01.03.01
EP 13
PC.01.02.03
EP 5
Consent Form
Consent form/ Anesthesia
Care Record
H& P form
OPERATIVE & OTHER PROCEDURES
32 Consent form present and signed, dated, and timed.
33 Type of sedation/anesthesia included on consent
form?
34 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
includes an update. The update includes an
examination and any changes to the patient's
condition)
Education Record "other"
All teaching fields specific to pain
are completed.
All teaching fields are appropriately
completed except pain
management teaching.
Signature(s) & initials are present
for appropriate disciplines.
Diagnosis, condition or indications
for use are documented anywhere
in the medical record including the
H&P
consent form present and signed,
dated and timed
Type of sedation/anesthesia
consent is documented
H&P on record prior to procedure/
surgery and w/in appropriate
timeframes:
35 Pre-procedural education documented before
operative or high-risk procedures or before moderate
or deep sedation or anesthesia.
36 Patient's condition is re-evaluated before administering
moderate or deep sedation.
PC.03.01.03
EP 4
37 "Time Out" documented before procedure.
UP.01.03.01
EP 5
PC.03.01.03
EP 8
38 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;
Documented
Sedation & Analgesia Record, ASA class and Pre-Sedation Status
Anesthesia record
completed for moderate or deep
sedation.
For OR area Anesthesia Care
Record ASA score prior to induction
completed.
Area Specific documentation
systems. Sedation/ Analgesia
Completed including date and time.
form.
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.
39 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 medical record 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.
RC.02.01.03
EP 5, 6 & 7
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.
40 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)
41 Discharge instructions form present and complete
(Outpatient areas)
42 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 documented
PC.04.01.05
need EP
PC.03.01.07
EP 6
Discharge instruction form
Form completed, dated, and timed.
CMS.482.51.(b)
Wiz or paper Patient
Discharge Instructions or
discharge letters per specialty Form completed, dated, and timed.