Patient Care Improvement
Tracer methodology is an evaluation method used by Joint Commission surveyors where they select a patient (resident or client) and use that individual’s record as a roadmap to move through an organization to assess and evaluate the organization’s compliance with selected standards and the organization’s systems of providing care and services. Surveyors retrace the specific care processes that an individual experienced by observing and talking to staff in areas that the individual received care. As surveyors follow the course of a patient’s treatment, they assess the health care organization’s compliance with Joint Commission standards. They conduct this compliance assessment as they review the organization’s systems for delivering safe, quality health care. ("Tracer Facts," 2012, para. 1)
For this assignment I have reviewed the tracer patient summary information and there are several outstanding patient care issues. Some of these are related to documentation, such as history and physical exam not completed timely, lack of documentation pertinent to functional assessment, plan of care documentation outdated, and the lack of pain assessment documentation following medication administration. I have elected to address the patient care issue of documentation since many elements of the patient tracer revealed documentation to be a concern. The old motto goes, “if it is not documented, it was not done”, therefore, appropriate documentation is critical not only for successful patient care, but also for the delivery of safe and quality health care.
Documentation is always a high risk item and often there will be deficiencies noted on audits and surveys due to the large number of requirements for same. Continued focus audits, random audits, and training will be necessary to continually improve on documentation. Training must focus not only on quality of timeliness, but also rules around timeliness, authentication, and appropriate use of abbreviations. Action plan below outlines recommended actions for improved compliance. Patient Tracer Action Plan: Documentation
No. Description Responsible Party Start Date End Date: Add’l Remarks
1 Audit H&P Completion on all new admissions daily basis looking for non-compliance. Documentation Specialist-HIMS Immediate 30 days Notification sent to responsible provider on a daily basis. Follow-up for compliance. Track results for repeat offenders.
2 Audit H&P Compliance on all new admissions for providers identified as repeat offenders during initial 30 day review. Documentation Specialist-HIMS 12-1-12 Ongoing Notification sent to responsible provider on a daily basis. Non-compliance will be tracked and become part of provider’s credentialing file.
3 Periodic random audit for H&P compliance on all new admission (select one day per month). Documentation Specialist-HIMS 12-1-12 Ongoing Notification sent to responsible provider on a daily basis. Non-compliance will be tracked and become part of provider’s credentialing file.
3 Provide mandatory documentation training to all care providers including physicians, nurses and ancillary providers (NP, PA’s etc.) HIMS Director 1-22-13 4-30-13 Cover requirements, timelines, importance, and details of adequate documentation.
4 Audit nursing plan of care for appropriate updates on surgical wards for a period of 30 days to identify trends. Nursing Supervisor Immediate 30 days Track for patterns of non-compliance and address non-compliance with appropriate staff.
5 Periodic random audit of nursing plan of care for staff identified as repeat offenders during initial audit. Nursing Supervisor 12-1-12 2-28-13 Review audit results with appropriate staff. Audit results will become part of employee’s performance review.
6 Audit documentation of post pain med administration effect within one hour. Nursing Supervisor Immediate 30 days Track for patterns of non-compliance and address non-compliance with appropriate staff.
7 Periodic random audit of post-pain med administration for staff identified as repeat offenders during initial audit Nursing Supervisor 12-1-12 2-28-13 Review audit results with appropriate staff. Audit results will become part of employee’s performance review. References
Facts about the Tracer Methodology. (2012). Retrieved from http://www.jointcommission.org/facts_about_the_tracer_methodology/