AFT Task 3

As our Joint Commission audit approaches, Nightingale Community Hospital has conducted a tracer patient survey to assess our compliance. The tracer methodology tracks a selected patient's care from admission to discharge, allowing us to evaluate our systems of providing care and to ensure that we are meeting the Joint Commissions standards of providing safe, quality healthcare.

Our tracer patient was a 67 year old female who presented with a fever and drainage five weeks after an open hysterectomy. She was admitted for a suspected postoperative infection,. She underwent another surgery to treat the abscess that formed from the initial surgery and had a central line inserted for long-term antibiotics. She is scheduled to go home with home health overseeing her antibiotic therapy.

This tracer patient has shown that there are areas of our patient care that we need to improve upon in order to be in compliance with the Joint Commission standards.

According to The Joint Commission (2014) compliance with standard PC.01.02.03 requires that a history and physical examination be done within 24 hours of inpatient admission and prior to surgery. In the case of this tracer patient, the history and physical was completed more than 72 hours after admission. Further, this patient underwent surgery two days after admission, prior to the completion of a history and physical exam.

The history and physical examination is a very important tool in a patient's care. It provides information regarding the patient's overall condition as well as potential risk factors that may affect the planned course of treatment. The history and physical allows the treatment team to determine if any additional interventions are required to reduce risk to the patient. The fact that this fundamental aspect was delinquent in this patient's care is unacceptable and a corrective