Physician Joint Commission Compliance
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IDENTIFICATION BADGE
• ALWAYS, ALWAYS wear your ID
• Your ID defines your role and access to
certain systems and locations
• Keep key contact info with your ID
2
GENERAL DOCUMENTATION
• Handwriting is legible
• Sign, date and time all entries
3
Patient Involvement
• Encourage the active involvement of
patients and their families in the patient’s
own care as a patient safety strategy
– Educate patients and families on methods
available to report concerns related to care,
treatment, services and patient safety issues
4
History and Physical
• H&Ps are complete
• All patients must have a H&P within 24
hours of admission
• If an H&P is > 24 hrs but less than 30 days
an interval update is acceptable
• Interval updates must address any and all
significant changes – USE THE FORM
• If > 30 days must have new H&P
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Pain Assessment
• Appropriate to the patient’s condition &
treatment
• Includes:
– Nature
– Location
– Duration
– Severity
– Reassessment after intervention (nursing)
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National Patient Safety Goal
Medication Reconciliation
• On admission: MD
– List pre-admission medications on the first (white) page
of med recon form; this serves as the medication
section of the H&P
– Reconcile on the third (pink) page – state whether each
home med will be continued or not continued
– Surgical patients admitted to hospital on day of surgery
• List pre-admission medications on med recon form in clinic
• Reconcile (pink page) at the time admit med orders are written
(PACU)
• On admission: RN
– Review home meds with patient, alert MD of any
discrepancy
– Verify the CPOE orders match the reconciled list, alert
MD if not consistent
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National Patient Safety Goal
Medication Reconciliation
• On Discharge:
– MD provides instructions for discharge meds
on first (white) page
– RN reviews med recon form and discharge Rx
with patient
– Patient is given white copy of med recon form
and pink copy of discharge Rx form
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Medication Orders
• Requirements
– Write legibly (for non-CPOE)
– RNs and/or pharmacy must clarify the order,
embrace requests for clarification
• PRN orders require a reason and range
clarification
• Avoid therapeutic duplication of orders
• Distinguish between types of medication and when
to use
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Medication Orders
• Write your own orders
• Understand the limitation of NP and PA
ordering privileges. RNs cannot write
orders
• Verbal orders require
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•
•
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RN to write the order
RN to read back the order
Provider must confirm the accuracy of read back
Must be signed off within 48 hours; any physician
of the treating team may sign off
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Restraints
• Requires a reason which is behavioral
• Requires face-to-face evaluation by MD
• Must be time limited, never more than 24
hours
• Type of restraint should be specified
• Use CPOE restraint order set, assures
compliance
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Diagnostic Testing
• Requirements:
– Test, side/site,
– Clinical condition being studied
– Any specific instructions
– e.g. mammogram - palpable right breast mass
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Informed Consent
– A discussion of risks and benefits as well as a
signed consent is required
– Consent form promotes compliance
– Require date and time on the physician
signature
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Sedation & Anesthesia
• Moderate sedation requires a specific DOP
(delineation of privileges)
• Minimum requirements:
– Assessment of heart and lungs
– Airway assessment
– Family/patient history of anesthesia/sedation
complications
– Plan for Sedation/Anesthesia
– CRNA’s plan must be approved by anesthesiologist
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Sedation Documentation Tool
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Pre-Procedure Assessment
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Universal Protocol
(Site Marking)
• MUST be done for procedures with laterality,
multiple structures, levels, even orifice with side
• MUST involve the patient, if possible
• MUST be unambiguous (no ‘x’, use initials)
• MUST be visible when prepped and draped
• DO NOT mark a non-operative site
• SHOULD be performed by the person
performing the procedure
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Universal Protocol
(Time Out)
• Requirements
– Immediately prior to any surgery or invasive
procedure
• Always includes procedure & patient ID
• Includes side/site and availability of diagnostic
studies or special equipment (if applicable),
including implantable items
• Includes bedside procedures, bronchoscopy, IR
procedures
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Safe Use of Medications
• Label all medications on and off the sterile
field
– Drug name, strength & amount
– Normal saline (even in a basin) and contrast
are medications
– Even if there’s only one medication in the field
– Many standard kits include pre-labeled
syringes
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Physician Documentation
Post Procedure
• Requires post anesthesia or sedation note
• Brief post op note written, in addition to
any dictated note
• Post op orders
• Medication reconciliation for same day and
same day admit surgeries/procedures
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National Patient Safety Goal
Patient Identification
• Requirements
– Two patient identifiers prior to medication,
blood, diagnostic study, procedure, treatment
• Patient Name – ask them to say their name, if
conscious (don’t offer their name and wait for a
‘yes’)
• Medical Record # (DOB is the second choice in
areas without arm bands)
– Confirm both prior to entering orders
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National Patient Safety Goal
Hand Offs
• Requirements
– Patient handoffs must contain standard
elements, including: diagnosis, current
condition, what to watch for in next interval of
care
– Opportunity to clarify & ask question
– Contact information (pgr #)
– Update who to call
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Document Critical Results
• If a nurse phones you with the critical test
results (or Radiology or Laboratory call
directly), repeat back the critical result to
the caller. If you’re on the unit, document
the result in the chart.
• Document what actions you took based on
the critical result. When you document the
critical result, date, time and sign your
entry.
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Infection Control
• Requirements
– No food/drink in the OR and in other patient
care areas
– Limited use of papers and lap top computers
– Adherence to standard based and
transmission precautions
– TB screening and Fit testing annually
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National Patient Safety Goal
Hand Hygiene
• Requirements
– Alcohol-based hand gel between patients
– Wash hands, soap and water, for at least 15
seconds when visibly soiled or caring for a
patient on C.difficile precautions
– No artificial finger nails (includes tips and
wraps) for direct caregivers; polish must be
intact
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National Patient Safety Goal
Unacceptable Abbreviations
• DO NOT USE
–
–
–
–
–
–
–
U
IU
QD
QOD
Trailing zero
MS
MgSO4
• Requirements
– Spell out “units”, “daily”, “morphine sulfate”, etc.
– Use a leading zero (0.1 mg), but not a trailing zero (5 mg)
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Suicide Risk
• Suicide is the #11 cause of death in the US (#3
in young people)
• Suicide in 24-hr facilities is the #1 sentinel event
reported to Joint Commission
• We must
– Identify patients at risk for suicide
– Address immediate safety needs, provide for a safe
environment
– Provide info (crisis hotline) to individuals and their
families for crisis situations
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