Joint Commission Pocket Guide for Physicians
Patient Care and Procedures
Hand Hygiene
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Strict adherence is expected. Soap and water requires a 15 second wash.
Use soap and water or antimicrobial towelette when visibly dirty, contaminated with
proteinaceous material, visibly soiled with blood or other body fluid, before eating, after
using a restroom, after suspected contact with Bacillus antharacis.
 Alcohol based hand rub or antimicrobial soap and water:
o Before having direct contact with patients, before donning sterile gloves when inserting a
central intravascular catheter, before inserting urinary catheters, peripheral vascular
catheters, or other invasive devices that do not require a surgical procedure.
o After contact with the patient's intact skin (eg. blood pressure, pulse, lifting), after
contact with body fluids, excretions, mucous membranes, non-intact skin, wound
dressings, and after removing gloves.
Requirements for Procedures
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When an informed consent is necessary it is documented prior to procedure.
Conduct and document a pre-sedation assessment prior to starting the procedure.
Conduct and document an immediate re-assessment just prior to starting anesthesia or
sedation.
If anesthesia is being administered by a non LIP, an LIP must concur with the anesthesia
plan and documents concurrence.
An operative or other high-risk procedure report is written or dictated upon completion of
the operative or other high-risk procedure and before the patient is transferred to the next
level of care. The exception to this requirement occurs when an operative or other high-risk
procedure progress note is written immediately after the procedure, in which case the full
report can be written or dictated within a time frame defined by the hospital.
The name(s) of the licensed independent practitioner(s) who performed the procedure and
his or her assistant(s), the name of the procedure performed, a description of the procedure,
findings of the procedure, any estimated blood loss, any specimen(s) removed, and the
postoperative diagnosis.
When a full operative or other high-risk procedure report cannot be entered immediately
into the patient’s medical record after the operation or procedure, a progress note that
includes the six elements noted above is entered in the medical record before the patient is
transferred to the next level of care.
A post-anesthesia evaluation is completed and documented by an individual qualified to
administer anesthesia no later than 48 hours after surgery or a procedure requiring
anesthesia services (note: not required for moderate sedation).
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Joint Commission Pocket Guide for Physicians
History and Physical
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Every inpatient needs a history and physical that is conducted or updated within 24 hours
after the admission or prior to a surgical procedure.
An H&P prepared in the community is acceptable if it was completed 30 days or less prior
to admission and is updated with 24 hours of admission or prior to a surgical procedure.
Site Marking
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Site marking is required for all invasive procedures other than: midline, single organ
procedures, endoscopies without intended laterality, or before procedures in which there is
no predetermined site of insertion.
Site marking must be done by a physician privileged for the procedure or an LIP that is
participating in the procedure and is familiar with the patient.
Mark the site with your initials (or per hospital policy) in a location visible after draping.
Timeout must be done for all invasive procedures and is done, ideally, prior to anesthesia
being administered. The entire team must participate in the timeout. No other activities
occur during the timeout. The three required elements of the time out are:
 Correct patient – use two identifiers
 Correct site - confirm with marking and relevant pre-procedure documentation
 Correct procedure – confirm with relevant pre-procedure documentation
If the surgeon is not present for the induction of anesthesia, then two complete timeouts
must be performed, one for the anesthesia, and another when the surgeon enters the room
for the planned procedure.
Label All Medications
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Label all medications and solutions on and off sterile field. Even sterile water and propofol
must be labeled.
Label all syringes, or basins when the solution is transferred to the syringe/basin
If you are the one drawing up the medication and you immediately use the medication and
immediately discard the empty syringe in a sharps container you do not need to label it. All
other situations require labeling!
The label must include the name, strength, quantity. If the med is not used within 24 hours,
you must include the date on label. If the amount of medication in the container is not
obvious, you need to include the amount.
You cannot label more than one med/solution at a time. (if you draw a medication into two
syringes, you must draw and label the 1st, then draw and label the 2nd)
The labeling expectation applies to diagnostic procedure settings, bedside procedures and
ambulatory sterile procedures also.
If you notice an unlabeled medication, it must be discarded immediately.
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Joint Commission Pocket Guide for Physicians
Critical Values
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Receive critical value results by writing down and reading back the critical value.
Restraints for Non Violent and Non Self Destructive Behavior
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Medical restraints used to protect the patient and prevent them from disrupting their own
care
Order by the LIP must be in the chart and must be reordered per your hospital policy
Restraints for Violent and Self destructive Behavior
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A physician must provide an order for restraint within one hour of V/SD restraint being
initiated.
An LIP or trained RN evaluates the patient within one hour
No orders for PRN restraint may be used.
Reorder if necessary in 4 hours for adults, 2 hours for adolescents 9-17 years old, 1 hour <9
years old, up to a maximum of 24 hours.
Consider, try and document restraint alternatives first.
Medication Orders, the Medical Record
Chart Entries and Physician Orders
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All chart entries and orders must be signed, dated, and timed.
All telephone orders must be authenticated by the prescriber or covering physician promptly
or as defined in state law.
Medication Orders
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All medication orders must be complete, legible dated, and timed.
All PRN orders need an indication for use.
“Resume All Orders” type orders are prohibited.
Our policy for medications brought to the hospital by the physician is xxxx.
Our policy for medications brought to the hospital by the patient is xxxxx.
Use the anticoagulation protocol for all patients on anticoagulation therapy.
Unapproved Abbreviations
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Do not use the following abbreviations: U, IU, QD, QOD, trailing zero x.0. lack of leading
zero .X mg, MS, MSO4, MgSO4
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Joint Commission Pocket Guide for Physicians
Medication Reconciliation
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Document the home medications for all inpatients or any outpatient receiving medications
during care.
Analyze the list and document decision making about home meds on admission.
Expect that a nurse or pharmacist will seek to reconcile any discrepancies between the home
list and the order.
In continuing ambulatory settings, ask the patient about any medication changes and update
the list accordingly. If you add or change medications, update the list and provide the patient
a copy of the updated list.
At the time of discharge or conclusion of an ambulatory treatment procedure, reconcile the
list, advise the patient what to take and what to stop, add any newly prescribed take home
medications to that list.
Do not use any Latin abbreviations on the take home list.
Problem List in Ambulatory Clinics
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Ensure that each continuing ambulatory patient has an up to date summary problem list. A
summary problem list is required for every outpatient that has 3 or more visits.
The list must contain documentation of all significant diagnoses and conditions, all
significant operative and invasive procedures, and all adverse and allergic drug reactions.
The summary problem list must document all medications used, or refer users to the med rec
list which contains a complete and up to date listing of all medications currently taken
including prescription, over the counter and herbal products.
Problem list should be reviewed and annotated at each visit and updated as appropriate.
Medical Staff Issues, Education and Leadership
Falsification & Reporting Safety Concerns
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Concerns you have about the safety or quality of care may be reported to the Joint
Commission without fear of retaliation.
The Joint Commission will consider as “falsification” or “fabrication” any instance of
completion of the post op note prior to the completion of the procedure, or pre signing order
forms for completion later, etc.
Medical Staff
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The director of emergency services is a member of the medical staff.
Contracts for contracted patient services are reviewed by the medical staff.
When an autopsy is performed, the MD is notified of results.
Medical Staff Bylaws to specify who can complete and document a H&P, this is specified
for each category of the medical staff.
Bylaws to specify the requirements of a complete H&P
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Joint Commission Pocket Guide for Physicians
Culture of Safety/Code of Conduct
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Physicians are trained on culture of safety and code of conduct.
Medical staff policy defines acceptable, disruptive and inappropriate behavior and a process
to address disruptive and inappropriate behavior
The hospital conducts surveys of staff attitudes to monitor and improve the culture of safety
Education Provided to the Medical Staff
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Medical staff are encouraged to participate in flu vaccine program
Physicians are trained on procedures to follow when the computer systems are down.
Physicians are trained on their role in a fire and their role in an emergency
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