Aft2 Task 3 Essay

805 Words Jun 10th, 2015 4 Pages
Accreditation audit
4 June 2015

Contents A. Tracer Audit 3 A1. Focus issue 3 A2. Corrective action 4 Works Cited 5

A. Tracer Audit
The tracer was performed as part of a process improvement to assess compliance with The Joint Commission standards (The Joint Commission, 2015). In this process, a random patient chart was chosen and the process followed from admission to discharge including any directly related follow-up or readmission.
The chart chosen for this tracer was for a 67-year-old female who underwent an open hysterectomy five weeks prior to hospitalization. The patient was admitted for post-op infection, abscess formation and drainage at the surgical site and fever seven days ago. Treatment consisted of surgical
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The history and physical is a very important tool for usage by the care team. It is used to provide an up to date picture of the patients overall condition as well as any historical risk factors or other conditions that may affect treatment. The H&P also informs all other care team members of the planned course of action for the patient so that they and the patient may be appropriately prepared for any upcoming treatment. That this patients history and physical was not updated as per protocol and that the patient was taken to surgery without it being updated shows that corrective action is need immediately to ensure safe and efficient patient care. It is imperative the H&P is completed as per hospital policy of within 24 hours of admission to maintain TJC standards compliance.

A2. Corrective Action Plan 1. The quality team will be tasked with completing 20 additional tracers in the next 30 days to assess the extent of this issue and ascertain whether it occurs randomly or frequently. The results of these additional audits will be given to the Chief Nursing Officer who will oversee any additional course of action initiated. 2. The hand-off process will be updated to include verification of H&P completion prior to the end of shift on the day of admission and any action taken by the nurse to obtain the H&P from the admitting or attending provider. 3. Attending and Admitting providers will be

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