Tracer Patient Assessment

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A1. Evaluation

In preparation for an upcoming Joint Commission inspection, Nightingale Community Hospital has conducted a mock tracer patient survey. The tracer method is the process of selecting a patient or case and following that case throughout the organization from admission to discharge and evaluating each department's compliance with Joint Commission standards. A mock tracer allows an organization to evaluate their processes for compliance and address any deficiencies in advance of an unannounced inspection.

This tracer followed a 67 year old female admitted with fever and drainage due a possible post-operative infection 5 weeks after an open hysterectomy. Five days prior to the tracer, the patient underwent surgery to treat
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All missing initial assessments will be investigated. The admitting nurse will be interviewed in each case to establish a root cause for non-compliance. The corrective action plan will include nurses on both shifts and the charge nurse on the unit and, be comprised of administrative and engineering controls to accomplish compliance, and conclude with staff education. Engineering controls will require time and resources to implement. Once the scope of the computer project has been determined and resources become available, this project should require little more than six weeks to implement. The administrative controls can be put into place as soon as documents are revised and introduced to staff. The entire process can be completed in two months.

1) Engineering control: The IT department will add an “Initial Assessment” to the nurse's work list in the patient's EMR that will be added automatically upon admission. This task will remain on their work list until it is completed. Both the admitting nurse and nurse coming on to the shift, or two nurses within the first 24 hours of admission, will be required to electronically acknowledge the results of the initial assessment within 24 hours of admission in the patient's
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Craig, P., Dolan, P., Drew, K., & Pejakovich, P. (2006). Nursing Assessment, Plan of Care, and Patient Education The Foundation of Patient Care. Retrieved November 2013, from http://www.hcmarketplace.com/

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