Tracer Record Review - Partial Hospitalization Program Only
12-20-12
Data Definition Tool
The Tracer Packet is to be completed in PHP 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.
Partial Hospitalization Program VPH: Monitor at
least 1 patient record per month using the Tracer
Record Review PHP Tool.
Screening and Assessment
1 Medical Record Number:
2
Health Screening completed upon admission.
3 Imminent risk to self or others screen complete
4 If imminent risk to self or others screen positive,
response to positive screening documented
5 Physical health screening completed within 2
treatment days by an RN (to determine need of a
medical hisotry and physical examination).
6 Patient and family's perception of needs, preference,
and goals for care, treatment, and service
documented.
7 Referred for medical history and physical examination
based on the physical health screening assessment.
Standard
No
YES
Positive screen follow up
documented on ?form;
or negative screen = NA
CTS.02.01.05,
EP1
Paper chart
CTS.02.01.01,
EP 1 & 2
NPSG.15.01.01,
EP 1
CTS.02.01.01,
EP 3,
Suicide Risk Assessment, Positive screen patient is Function screen section incomplete
paper chart
admitted
CTS.02.01.03,
EP 1 & 2
Health Screening Form,
Paper chart under the
Misc tab
Health Screening
Completed
CTS.02.01.03,
EP 3 & 4
Progress Notes,
Treatment Plan tab
Family listed as involved.
CTS.02.01.05,
EP 1, 2, 3, & 4.
Health Screening Form,
Paper chart under the
Misc tab
Positive screen follow up Positive screen & no documentation of followup.
documented on form ; or
negative screen = NA
Nursing Admission
Assessment, Star Panel
Pain screen completed
Pain screen incomplete
Health Screening Form,
Paper chart under the
Misc tab
Positive screen follow up
documented on form; or
negative screen = NA
Positive screen & no documentation of follow up.
Health Screening Form,
Paper chart under the
Misc tab
Nutrition screen
completed
Nutrition screen & no documentation of follow-up.
8 Pain screen complete
CTS.02.01.09,
EP 1 & 2
9 If pain screen positive, plans for follow-up documented CTS.02.01.09,
EP 1 & 2
10 Nutrition screen complete
Location
CTS.02.01.11,
EP 1
Suicide Risk Assessment, Positive screen follow up Positive screen & no documentation of followup.
on star panel
documented on ?form;
or negative screen = NA
Health screen incomplete.
11 If nutrition screen positive, plans for follow-up
documented
CTS.02.01.11,
EP 2 & 3
Health Screening Form,
Paper chart under the
Misc tab
12 Abuse, trauma, neglect, or exploitation screen
complete
CTS.02.02.05,
EP 1, 2 & 3,
RI.01.06.03, EP
1, 2, 3, & 7
CTS.02.02.05,
EP 4, 5 & 6
Psychosocial Assessment, Abuse screen completed Social Environment screen incomplete.
star panel
13 If abuse, trauma, neglect, or exploitation screen
positive, plans for follow-up documented
Positive screen follow up
documented on form; or
negative screen = NA
Psychosocial Assessment, Positive screen and
star panel
referral source follow up
documented on form; or
negative screen = NA
Positive screen & no documentation of follow up.
Positive screen & no documentation of follow up
15 Was the medication reconciliation completed upon first
contact and updated when the patient's medications
changed?
Plan of Care
17 Plan of Care complete (includes needs, strengths,
preferences, and goals).
NPSG.03.06.01 PAE, star panel
EP 1
Documented in chart? Y/
N
CTS 03.01.03,
EP 1, 2, & 3
Treatment Plan, under the Includes needs,
Treatment plan tab, paper strengths, preferences,
chart
goals and objectives.
Does not include all elements.
18 Plan of Care re-evaluated and revised.
CTS 03.01.03,
EP 4,
Treatment Plan,
Nursing Assessment,
Psychological
Assessment.
Does not include all elements.
19 Plan of Care includes reasons for deferring a goal or
objectives related to a goal.
CTS 03.01.03,
EP 5,
Treatment Plan, under the Documented, N/A
Treatment plan tab, paper
chart
Not Documented
20 Care, Treatment ,and Service is provided according
the Treatment Plan
CTS 03.01.03,
EP 6,
Treatment Plan, under the Documented
Treatment plan tab, paper
chart
Not Documented
21 Plan of Care, Treatment, and Service includes family
involvement
CTS 03.01.05,
EP 1, 2 & 3
Treatment Plan, under the Documented family
Treatment plan tab, paper involvement in
chart
developing the plan and
family participation
(unless contradicted).
Not Documented
22 Care, Treatment ,and Service is provided according
the organization's scope of care, treatment, and
service
23 Coordinates care referrals with internal and external
resources.
CTS 04.01.01
Treatment Plan, under the Documented
Treatment plan tab, paper
chart
Not Documented
CTS 04.01.01,
EP 3, 4, & 5
Treatment Plan, under the Documented
Treatment plan tab, paper
chart
Not Documented
24 Plan of Care activities have timeframe
CTS 04.01.01,
EP 8
Treatment Plan, under the Documented
Treatment plan tab, paper
chart
Not Documented
Based on change in the
individual's needs,
preferences, goals,
response to care,
treatment, and service.
CTS.03.01.03,
EP 3
Treatment Plan, under the Documented
Treatment plan tab, paper
chart
CTS 04.01.03,
EP 1, 4
Treatment Plan, under the Education includes Plan
Treatment plan tab, paper of CTS, basic health and
chart
safety, safe/effective use
of medications, nutrition,
habitation/rehabitation.
28 Learning needs based on the individual.
CTS 04.01.03,
EP 2, 5, 6,
Psychosocial Assessment, Includes cultural/religious
star panel
beliefs, emotional
barriers,
desire/motivation to
learn, physical/cognitive
limitations, barriers to
communication.
29 The individual's cpmprehension of the education
provided is evaluated.
30 Education coordinated among disciplines.
CTS 04.01.03,
EP 7
CTS 04.01.03,
EP 3
Progress notes, star panel Documented
CTS 06.02.01,
EP 1
CTS 06.02.03,
EP 1
Discharge Summary, star
panel
25 Treatment Plan includes objectives
PATIENT EDUCATION
27 Education is based on needs and abilities of the
patient
Discharge
31 Discharge process addresses continuity of care,
treatment, or service after discharge or transfer.
32 The physical and psychosocial needs are identified at
discharge for continuing care.
Not Documented
Treatment Plan, under the Documented in treatment Not documented.
Treatment plan tab, paper plan.
chart
Discharge Summary, star
panel