Critical Access Hospital Audit
**The following checklist will be presented to each Department Head upon arrival at facility.
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Incident Reports for the past year
List of grievances/complaints
List of Current Patients (include name, diagnosis, admit date, physician, Note (**acute care or **swing bed)
List of Discharged patients for the last 3 months-Please include name, diagnosis, admit date, discharge
date, physician, **acute care or **swing bed
List of ALL staff (clinical, non-clinical, agency, contractors, physician, allied health)
Emergency Room – Log Book for last 6 months, and Policies, transfer and consultation agreements with
other hospitals.
Surgery & Procedure Log for last 6 months
Organizational Chart with names and titles
List of Contracted Services and Agreements
Anesthesia and Surgery: Policies and Procedures Table of Contents
Governing Body: Bylaws, meeting minutes for the past year
Medical Staff: Bylaws, Rules and Regulations, meeting minutes for the past year.
Nursing: Policies and Procedures Table of Contents
Dietary: Policies and Procedures, consultant dietitian report, copy of nutritional screening from, Dietary
Manual
Quality Improvement: plan & meeting minutes for the past year-include yearly evaluation for the entire
program.
Laboratory: list of services provided and CLIA certificate
Infection Control: Policies and Procedures; infection control log; current plan; all surveillance/monitoring
activities & meeting minutes for the past 12 months, Infection Control Practitioners name & personnel file
with education.
Organ Procurement: list of all (ER & Inpt) Deaths for the past year; contract with Life Share (organ
procurement agency) & Activity Reports from Life Share for the same time period; policies/protocols
concerning reporting to Life Share
Swing Bed: Policies and Procedures; activities person (name & credentials); Social services person;
Abuse policies (allegations against employees)
Health screening policy for employees and other workers
Radiology: list of qualified personnel; current permit; radiation badge reports; physicists report, policies and
procedures, competencies for staff; Name of Chief Radiologist and credentialing file
Pharmacy: Policies and Procedures, Consultant pharmacist reports for last 12 months, Pharmacy &
therapeutics committee meeting minutes for past 12 months, & Drug Formulary
Physical Therapy: Policies and Procedures
Respiratory Therapy: Policies and Procedures, nurse competency training
Emergency Disaster Plan: Drills for past year