Quality & Patient Safety
Quality improvement and patient safety programs.
- Details
- Category: Quality & Patient Safety
Clinical Documentation Standards and Requirements
Fundamental Principles of Clinical Documentation
Documentation Must Be:
- Accurate - Reflects the true clinical picture
- Complete - Contains all relevant information
- Timely - Documented at or near the time care is provided
- Legible - Readable by others
- Authenticated - Signed/co-signed by responsible provider
- Objective - Based on observations, not assumptions
Legal Requirements
- The medical record is a legal document
- Document only what you personally observed, did, or were told
- Use quotes for patient statements
- Never alter, backdate, or falsify documentation
- Late entries must be clearly labeled
Admission Documentation Requirements
History and Physical (H and P) - Physician
Timeframe: Must be completed within 24 hours of admission
Required Components
| Section | Required Elements |
|---|---|
| Chief Complaint | Reason for admission in patient own words |
| History of Present Illness | OLDCARTS: Onset, location, duration, character, aggravating/relieving factors, timing, severity |
| Past Medical History | Chronic conditions, prior hospitalizations, surgeries |
| Medications | Current medications with doses, frequency, route |
| Allergies | Drug allergies with specific reaction |
| Family History | Relevant conditions in first-degree relatives |
| Social History | Tobacco, alcohol, drug use; occupation; living situation |
| Review of Systems | Systematic review of all organ systems |
| Physical Examination | Comprehensive or focused exam; must include vital signs |
| Assessment | Working diagnosis/diagnoses |
| Plan | Diagnostic workup, therapeutic interventions, consultations |
Nursing Admission Assessment
Timeframe: Must be completed within 8 hours of admission
Required Components
- Patient identification verification
- Chief complaint and history
- Allergies with reactions
- Current medications (reconciliation completed)
- Pain assessment
- Vital signs with height and weight
- Head-to-toe physical assessment
- Fall risk assessment (Morse Fall Scale)
- Skin assessment (Braden Scale)
- Nutritional screening
- Advance directives status
- Details
- Category: Quality & Patient Safety
Patient Safety Protocols and Infection Prevention
Universal Patient Safety Goals
National Patient Safety Goal 1: Patient Identification
Requirement: Use at least two patient identifiers when providing care.
Acceptable Identifiers
- Full legal name (as appears on ID band)
- Date of birth
- Medical record number (MRN)
NOT Acceptable as Identifiers
- Room number
- Bed location
- Physical appearance alone
Identification Required Before
- Medication administration
- Blood/blood product transfusion
- Specimen collection and labeling
- Procedures and treatments
SBAR Communication Framework
| Component | Description |
|---|---|
| S - Situation | What is happening now? |
| B - Background | Relevant clinical context |
| A - Assessment | What do you think the problem is? |
| R - Recommendation | What do you want to happen? |
Read-Back Verification (Required)
For verbal/telephone orders and critical test results:
- Write down the complete order or result
- Read back the information to the sender
- Receive confirmation that information is correct
High-Alert Medications
Definition: Medications that bear heightened risk of significant patient harm when used in error
| Category | Examples | Safety Measures |
|---|---|---|
| Anticoagulants | Heparin, Warfarin, DOACs | Independent double-check, standardized protocols |
| Insulin | All types | Independent double-check, glucose monitoring |
| Opioids | Morphine, Hydromorphone, Fentanyl | PCA protocols, sedation monitoring |
| Neuromuscular Blockers | Rocuronium, Succinylcholine | Auxiliary labels, OR/ICU only |
| Concentrated Electrolytes | KCl, Hypertonic saline | Remove from patient care areas |
| Chemotherapy | All agents | Independent double-check, dedicated area |