Record Review Emergency Department Only 12-18-15
Data Definition Tool
The Tracer Packet is to be completed in each inpatient unit by the manager or designee on a monthly basis.
Tracers are due on the last day of the month following the review (example: July Tracer due July 31).
* IP = Inpatient; w/in = within
Instructions: Indicate Yes, No, NA (Not
Applicable) for each question below.
Emergency Areas : Monitor at least 1 patient
Standard
Location
YES
record per month using the Tracer Record Review
Emergency Department Tool.
ADMISSION
1 Medical Record Number:
HED: Admission All components
2 Initial nursing history completed within 24 hours of PC.01.02.03
History tab or
completed & signed
admission (those that are admitted as InPatient) EP 2 & 6
paper record
by RN w/in
Admission
timeframe as
/History/
indicated on (1)
Discharge form
Time of Medipac
transaction to admit;
(2) Time order
written in CPOE; or
(3) Time on Nursing
Admission History
3 Suicide Risk screening completed for patients with NPSG.
emotional or behavioral chief complaint?
15.01.01
EP 1
4 If Suicide Risk screen positive, follow-up includes
provider assessment and environmental
assessment.
NPSG.
15.01.01
EP 1
Emergency Department:
5 Time and means of arrival.
RC.02.01.01
EP 21
6 Indication that the patient left against medical
advice, when appropriate.
MEDICATION ADMINISTRATION
7 Are orders for PRN medications specific such that
there is no therapeutic duplicatoin (multiple options
for a specific indication?
RC.02.01.01
EP 21
Triage Form
Pt with emotional or
behavioral chief
complaint and
suicide risk
assessment
completed.
VPH - in suicide
Nursing
screen section.
environmental
Other HED areas - assessment and
in Safety
provider
interventions.
assessment is
Provider
documented.
assessment would
be in StarPanel.
ED Triage form or
ED Nursing
Assessment
LWBS/AMA form
and ED Nursing
Assessment
Medications list
documentation
present
documentation
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).
Conclusions at the Termination of Care,
Treatment, services:
8 Final Dispostion.
9 Condition at discharge.
Instructions for follow-up care, treatment, or
10 services.
RC.02.01.01
EP 21
RC.02.01.01
EP 21
RC.02.01.01
EP 21
A copy of any information made available to the
practitioner or medical organization providing follow- RC.02.01.01
EP 21
11 up care, treatment, or services.
ED Nursing
Assessment form
ED Nursing
Assessment form
ED Nursing
Assessment form
In the patient's
electronic chart discharge
instructions.
documentation
present
documentation
present
documentation
present
documentation
present