Accreditation Audit – Task 3
Western Governors University
, Introduction
Nightingale Community Hospital recently completed a patient care
tracer focused on a surgical patient. The patient, a 67-year-old female was
admitted 5 weeks after surgery for an open hysterectomy after failed
laparoscopic hysterectomy. The patient was readmitted to the hospital 7
days ago after developing drainage and high fever. Five days prior to the
tracer, the patient had surgery to treat the abscess that had formed and to
place a central line for long-term antibiotics. The patient will be discharged
home with home health to manage ongoing antibiotics. This tracer follows
the patient's admission and interactions with the Surgical Nursing Unit
Radiology, OR, and PACU.
A1 - Evaluation
Upon completion of this tracer, several deficiencies were noted in the
environment of care. After review, it was noted that the patient’s history and
physical (H&P ) was not completed within 24 hours of admission. The staff
member interviewed for this component noted that the documentation was
completed more than 72 hours after admission
Joint Commission standard PC.01.02.03 states the hospital assesses
and reassesses the patient's condition within defined time frames. More
specifically, EP 4 of this section provides a timeframe for completing an H&P
no more than 30 days prior to or within 24 hours after registration or
inpatient admission but prior to surgery or procedures requiring anesthesia
Western Governors University
, Introduction
Nightingale Community Hospital recently completed a patient care
tracer focused on a surgical patient. The patient, a 67-year-old female was
admitted 5 weeks after surgery for an open hysterectomy after failed
laparoscopic hysterectomy. The patient was readmitted to the hospital 7
days ago after developing drainage and high fever. Five days prior to the
tracer, the patient had surgery to treat the abscess that had formed and to
place a central line for long-term antibiotics. The patient will be discharged
home with home health to manage ongoing antibiotics. This tracer follows
the patient's admission and interactions with the Surgical Nursing Unit
Radiology, OR, and PACU.
A1 - Evaluation
Upon completion of this tracer, several deficiencies were noted in the
environment of care. After review, it was noted that the patient’s history and
physical (H&P ) was not completed within 24 hours of admission. The staff
member interviewed for this component noted that the documentation was
completed more than 72 hours after admission
Joint Commission standard PC.01.02.03 states the hospital assesses
and reassesses the patient's condition within defined time frames. More
specifically, EP 4 of this section provides a timeframe for completing an H&P
no more than 30 days prior to or within 24 hours after registration or
inpatient admission but prior to surgery or procedures requiring anesthesia
