Nightingale Community Hospital Patient Tracer Summary
Nightingale Community Hospital: Patient Tracer Summary
Western Governors University
Nightingale Community Hospital: Patient Tracer Summary
Nightingale Community Hospital utilizes a tracer methodology adapted from The Joint Commission to review patient charts weekly. The tracer method provides a precise appraisal of programs and methods for delivery of care and services. A thorough review of current services will help identify possible deficiencies.
Patient 453355 medical record was audited by the Risk Management department to review care and services received through departments from admission through discharge at NCH. This patient was admitted with a post-operative wound infection. The Joint Commission standards were adhered to and a Surgical Patient Tracer worksheet was utilized. A deficiency was identified within the “read back” policy, which addresses physician notification upon acknowledgement of a critical lab value. Hospital staff interviewed was unable to explain the read back procedure upon delivery of critical lab values. The same staff also could not explain the documentation needed when critical lab value notification occurs. The Joint Commission Provision of Care …show more content…
Departmental managers and staff from laboratory, radiology, cardiopulmonary and nursing participated as committee members. The committee members reviewed Joint Commission National Patient Safety Goal 2 safety reports (2010), scrutinized communication processes and additional patient charts were audited for critical lab value documentation. The committee members discovered a breakdown at the point of documentation in the read back procedure. The read back procedure was being carried out, however the nurses had difficulty in consistently documenting when a report was received due to lack of computer
Western Governors University
Nightingale Community Hospital: Patient Tracer Summary
Nightingale Community Hospital utilizes a tracer methodology adapted from The Joint Commission to review patient charts weekly. The tracer method provides a precise appraisal of programs and methods for delivery of care and services. A thorough review of current services will help identify possible deficiencies.
Patient 453355 medical record was audited by the Risk Management department to review care and services received through departments from admission through discharge at NCH. This patient was admitted with a post-operative wound infection. The Joint Commission standards were adhered to and a Surgical Patient Tracer worksheet was utilized. A deficiency was identified within the “read back” policy, which addresses physician notification upon acknowledgement of a critical lab value. Hospital staff interviewed was unable to explain the read back procedure upon delivery of critical lab values. The same staff also could not explain the documentation needed when critical lab value notification occurs. The Joint Commission Provision of Care …show more content…
Departmental managers and staff from laboratory, radiology, cardiopulmonary and nursing participated as committee members. The committee members reviewed Joint Commission National Patient Safety Goal 2 safety reports (2010), scrutinized communication processes and additional patient charts were audited for critical lab value documentation. The committee members discovered a breakdown at the point of documentation in the read back procedure. The read back procedure was being carried out, however the nurses had difficulty in consistently documenting when a report was received due to lack of computer