JCI第四版教學講解課件

InternationalPatientSafetyGoals(IPSG)

1InternationalPatientSafetyGImprovingPatientSafety

means...ReducingMedicalErrorsReducingPatientHarmImprovingPatientSafety

meansChallengesforPatientSafetyLeadership

Movetowardamoresafety-orientedculturePracticeproactivesystemsanalysis&riskreductionStandardizeprocessesandequipmentPromoteeffectivecommunicationEnsureadequateandeffectivestaffingImplementteamtrainingforallstaffEncourageandsupportpatientinvolvementChallengesforPatientSafetySystemsAnalysisinHealthCare

Asystematicevaluationofahealthcareorganization’ssystemsandprocesses:

Toidentifyvulnerabilitiesandhazardousconditionsthatcould(and,overtime,will)impactpatientsafetyandqualityofcare.Tofocustheredesignofthosesystemsandprocessestoimprovepatientsafetyandqualityofcare.SystemsAnalysisinHealthCarImplementationofIPSG….RepresentsproactivestrategiestoreduceriskofmedicalerrorandreflectgoodpracticesproposedbyleadingpatientsafetyexpertsIncorporatingthesenewtoolsintoouraccreditationrequirementsisasignificantstepOrganizationstakingresponsibilityforusingtheIPSGtofosteranatmosphereofcontinuousimprovementisevenmoreimportantImplementationofIPSG….RepresJCI4thEditionInternationalPatientSafetyGoalsPSG1 IdentifyPatientsCorrectlyPSG2 ImproveEffectiveCommunicationPSG3 ImprovetheSafetyofHigh-AlertMedicationsPSG4 EnsureCorrect-Site,Correct-Procedure,Correct-PatientSurgeryPSG5 ReducetheRiskofHealthCareAssociatedInfectionsPSG6 ReducetheRiskofPatientHarmResultingfromFallsJCI4thEditionInternationalIPSG.1

IdentifyPatientsCorrectlyAcollaborativeprocessisusedtodeveloppoliciesand/orproceduresthataddresstheaccuracyofpatientidentification

Useatleasttwo(2)waystoidentifyapatient:givingmedicationsgivingbloodandbloodproductstakingbloodsamplestakingothersamplesforclinicaltestingprovidingtreatmentorprocedureThepatient’sRoomNumbercannotbeusedasanidentifier

IPSG.1

IdentifyPatientsCorreThecompleteVOandTOortestresultiswrittendownbythereceiveroftheorderortestresult.Mustuseaverification“readback”ofcompleteorderortestresultTheorderortestresultisconfirmedbytheindividualwhogavetheorderortestresultPoliciesandproceduressupportconsistentpracticeverifyingtheaccuracyofverbalandtelephonecommunicationsIPSG2:ImproveEffectiveCommunicationThecompleteVOandTOortestPolicies/proceduresaredevelopedtoaddressidentification,location,labelingandstorageofhigh-alertmedicationsPolicies/proceduresareimplementedConcentratedelectrolytesarenotpresentinpatientcareunitsunlessclinicallynecessaryandactionsaretakentopreventinadvertentadministrationConcentratedelectrolytesthatarestoredinpatientcareunitsareclearlylabeledandstoredinamannerthatrestrictsaccessIPSG3:ImproveSafetyofHighAlertMedicationsPolicies/proceduresaredeveloClinicalNecessityHastobesupportedbyevidenceIsthesubstancereallyneededveryquickly?Ifitisusedtodilute,isthedilutedsolutionavailable?ClinicalNecessityHastobesuIPSG4:EnsureCorrect-site,Correct-procedure,Correct-patientSurgeryCollaborativelydevelopapolicy/procedurethatincludes:Definitionofsurgerythatincorporatesatleastthoseproceduresthatinvestigateand/ortreatdiseasesanddisordersofthehumanbodythroughcuttingremoving,altering,orinsertionofdiagnostic/therapeuticscopes.IPSG4:EnsureCorrect-site,CIPSG4CorrectSite,ProcedureandPatient

UseaninstantlyrecognizablemarkforsurgicalsiteidentificationInvolvesthepatientinthemarkingprocessInvolvesthefullsurgicalteamandisdocumentedjustbeforestartingasurgicalprocedurePolicies/proceduresaredevelopedtosupportuniformprocesstoensurecorrectsite,procedure,andpatient(includingmedicalanddentalproceduresdoneinsettingsotherthantheoperatingtheater)IPSG4CorrectSite,ProcedureChecklistorotherprocesstoverify:CORRECTSURGERYSITEDOCUMENTSEQUIPMENTFunctional&CorrectPROCEDUREPATIENTChecklistorotherprocesstoPSG5:ReducetheRiskofHealthCare-AssociatedInfectionsNeeddatatodemonstrateeffectivenessTheorganizationhasadoptedoradaptedcurrentlypublishedandgenerallyacceptedhand-hygieneguidelinesImplementsaneffectivehand-hygieneprogramPolicies/proceduresaredevelopedthatsupportcontinuedreductionofhealthcareassociatedinfectionsPSG5:ReducetheRiskofHealIPSG6:ReducetheRiskofPatientHarmresultingfromFallsImplementsaprocessfortheinitialassessmentofpatientforfallriskandreassessmentofpatientswhenindicatedbyachangeinconditionormedications,amongothersMeasuresareimplementedtoreducefallsriskforthoseatriskIPSG6:ReducetheRiskofPatIPSG6ReducingRiskofHarmResultingfromFallsMeasuresaremonitoredforresults,bothsuccessfulfallinjuryreductionandanyunintentionalrelatedconsequencesPolicies/proceduressupportcontinuedreductionofriskofpatientharmresultingfromfallsintheorganizationIPSG6ReducingRiskofHarmRThankYouNextPresentationThankYouNextPresentationAccesstoCareand

ContinuityofCare(ACC)18AccesstoCareand

ContinuityACC-FiveAreasofFocusAdmissiontotheOrganizationContinuityofCareDischarge,Referral,andFollow-upTransferofPatientsTransportationACC-FiveAreasofFocusAdmissiACC.1“ADMISSION”ofIn-Patients&“REGISTRATION”ofOut-PatientsScreeningatpointoffirstcontactDetermineifcarecanbeprovidedDiagnostictestareavailablefordecisionmaking-standardizedbypolicyPatientsareinformedifanywaitordelayandreasons(waitinglist)ACC.1“ADMISSION”ofIn-PatienACC.1.1ProcessofAdmissionorRegistrationPolicies&Procedures(PP)standardizeadmissionandregistrationforout-patientsandin-patientsPPAdmittingemergencypatientsPPHoldingpatientsforobservationPPManagingpatientswhenbedspacenotavailableACC.1.1ProcessofAdmissionoACC.1.1.1EmergencyPatientsEvidencebasedtriageprocessisusedtoprioritizepatientswithimmediateneedsStaffaretraineduseofthetriageprocessStaffprioritizepatientsbasedonurgencyofneedsEmergencypatientsareassessedandstabilizedpriortotransferACC.1.1.1EmergencyPatientsEvACC.1.1.2NeedsarePrioritized

forIn-patientsScreeningassessmentidentifiespatient’sneedsServicesorunitsareselectedtomeetneedsbasedontheassessment:–Preventative–Palliative–Curative–RehabilitativeACC.1.1.2NeedsarePrioritizACC.1.1.3WaitingPeriodsorDelays

In-patientsandout-patientsareinformedofdelaysReasonfordelayandavailablealternativesDocumentedinthepatientmedicalrecordWrittenpolicies/proceduresACC.1.1.3WaitingPeriodsorDACC.1.2InformationProvidedPatientandFamilyreceiveinformationduringtheadmissionprocesson:ProposedcareExpectedoutcomesofcareExpectedcostsSufficientinformationtomakeknowledgeabledecisionsACC.1.2InformationProvidedPaACC.1.3ReductionofBarriersLeadersandstaff

identifymostcommonbarriersforpatientsPhysicalLanguageCulturalOtherAprocessisidentifiedandimplementedtoovercomeorlimitidentifiedbarrierstolimitimpactofbarriersondeliveryofservicesACC.1.3ReductionofBarriersLACC.1.4CriteriaforAdmissionorTransfertoIntensiveCareAdmission/transfercriteriaestablishedforIntensiveandSpecializedUnitsCriteriaarephysiologic-basedAppropriateindividualsareinvolvedindevelopingandimplementingthecriteriaPatientsmeetthecriteria(documented)Patientsaredischarged/transferredwhentheynolongermeetcriteriaACC.1.4CriteriaforAdmissionACC.2ContinuityofPatientCare

Leadersdesignandsupportcontinuity(coordination&resources)CriteriaorpoliciesdeterminetransferswithintheorganizationContinuityandcoordinationisevidentthroughoutallphasesofpatientcareandtothepatientACC.2ContinuityofPatientCaACC.2.1IndividualResponsibleThereisanindividualresponsibleforpatient’scarewhois

aphysicianorotherpersonqualifiedtoassumeresponsibilityforcareidentifiedtothehospitalstaffTheindividualdocumentsthepatientplanofcareTransferfromoneindividualtoanotherisdescribedinpolicyACC.2.1IndividualResponsibleACC.3ReferralandDischargePolicyPolicyfortheappropriatereferralordischargeofpatientsBasedonpatient’sneedsforcontinuingcareThepatient’sreadinessfordischargeDischargeplanningbeginsearlyandincludesthefamilyasappropriatePolicyguidespatients“onpass”foradefinedperiodoftimeACC.3ReferralandDischargePACC.3.1CooperationwithCommunityPractitioners

Dischargeplanningforbothsupportive

andcontinuingmedicalservicesCommunityproviders,organizationsandindividualsareidentifiedAppropriatereferralsaremade(inthepatient’shomecommunitywheneverpossible)ACC.3.1CooperationwithCommuACC.3.2DischargeSummaryIn-patientclinicalrecordscontainadischargesummarypreparedbyaqualifiedindividualFollowupinstructionsCopiesare:Inthepatient’smedicalrecordGiventothepatientatdischargeProvidedtopractitionerresponsibleforcontinuedcarePolicyandproceduredefinedischargesummaryACC.3.2DischargeSummaryIn-paACC.3.2.1DischargeSummaryPreparedatdischarge,documentedinthepatient’srecordandcontains:ReasonforadmissionSignificantphysicalandotherfindingsSignificantdiagnosesandco-morbiditiesDiagnosticandtherapeuticproceduresSignificantmedicationandtreatmentsConditionatdischargeDischargemedicationsandallmedicationstobetakenathomeFollowupinstructionsContinuedonnextslide…..ACC.3.2.1DischargeSummaryPreACC.3.2DischargeSummaryUnlesscontrarytopolicy,laws,orculture,patientsaregivenacopyAcopyisprovidedtothepractitionerresponsibleforpatient’scontinuingorfollow-upcareACC.3.2DischargeSummaryUnlesACC.3.3OutPatientSummaryofContinuingCareIdentifywhichcontinuingcarepatientsrequireasummaryIdentifyhowthesummaryismaintainedandwhomaintainsitIdentifyformatandcontentofsummaryDefinewhatisconsideredcurrentPolicyforcompletedsummaryACC.3.3OutPatientSummaryofACC.3.4UnderstandableFollowUpInstructionsFollowupinstructionsareunderstandableReturnforfollowupcareWhentoobtainurgentcareCarenecessarytopatient’sconditionACC.3.4UnderstandableFollowACC.3.5AgainstMedicalAdviceProcessformanagementandfollowupofin-patientsandoutpatientswholeaveAMAKnownfamilyphysiciansarenotifiedApplicablewithlocallawsandregualtionsACC.3.5AgainstMedicalAdviceACC.4TransferPolicyGuidingprocessfortransferringpatientstoinclude:Patient’sneedforcontinuingcareTransferofresponsibilitytoanotherproviderorsettingWhoisresponsibleduringtransferSituationswheretransferisnotpossibleACC.4TransferPolicyGuidingpACC.4.1ReferringandReceivingOrganizationsReferringorganizationdetermineswhetherreceivingorganizationcanmeetpatient’sneedsArrangements(formalorinformal)areinplacewhenpatientsarefrequentlytransferredACC.4.1ReferringandReceivinACC.4.2WrittenSummaryClinicalsummaryistransferredwithpatient&includes:PatientstatusProceduresOtherinterventionsprovidedPatient’scontinuingcareneedsACC.4.2WrittenSummaryClinicaACC.4.3MonitoringPatientsDuringTransferAllpatientsaremonitoredduringdirecttransferQualificationsofthestaffmemberdoingthemonitoringareappropriateforpatient’sconditionACC.4.3MonitoringPatientsDuACC.4.4DocumentationofTransferDocumentationincludes:NameoforganizationandindividualagreeingtoreceivepatientReasonfortransferAnyspecialconditionsrelatedtotransferAnychangeofpatient’sconditionorstatusduringtransferAnyothernotesrequirebythetransferringorganizationACC.4.4DocumentationofTransACC.5PlanningTransportationNeedsAssessmentoftransportationneedswhenreferringpatientsTransportationisarrangedappropriatetopatientneedsOwnedtransportvehiclesmeetlawsandregulationsContractedtransportationmeetspatientneedsAppropriateequipmentMonitoringthequalityandsafetyortransportationIncludesacomplaintprocessACC.5PlanningTransportationThankYouNextPresentationThankYouNextPresentationPatientandFamilyRights(PFR)45PatientandFamilyRights(PFRPFR–SixAreasofFocusIdentify,ProtectandPromotePatientRightsInformPatientsofTheirRightsIncludingPatient’sFamilyinDecisionsInformedConsentResearchOrganDonationPFR–SixAreasofFocusIdentiPFR.1ProcessesSupportRightsLeadersworkcollaborativelytoprotectandadvancepatientandfamilyrightsunderstandrightsasdefinedinlawsandregulationsStaffmembersareknowledgeableandcanexplaintheirresponsibilitiesPoliciesandProcedures(PP)guideandsupportpatientandfamilyrightsContinuedonnextslidePFR.1ProcessesSupportRightsPFR.1ProcessSupportRightsThehospitalrespectspatientrights,andinsomecasestherightsofpatient’sfamily:tohavetheprerogative

todeterminewhatinformationisprovidedthefamilyandothers,andunderwhatcircumstances.PFR.1ProcessSupportRightsThPFR.1.1Patient’sValuesandBeliefsThereisahospitalprocesstoidentifyandtorespectpatientvaluesandbeliefsandthoseofthefamilyStaffmembersusetheprocessprovidecarerespectfulofthepatient’svaluesandbeliefsPFR.1.1Patient’sValuesandBPFR.1.1.1SpiritualSupportThereisaprocesstorespondtorequestsforreligiousorspiritualsupportProcessisdesignedtoaccommodate:RoutinerequestsComplexrequestsPFR.1.1.1SpiritualSupportThePFR.1.2PatientPrivacyStaffmembersidentifypatientexpectationsandneedsforprivacyThepatient’sexpressedneedforprivacyisrespectedinall:ClinicalinterviewsExaminationsProcedures/treatmentsTransportPFR.1.2PatientPrivacyStaffmPFR.1.3PatientPossessionsThehospitaldefinestowhatextentitisresponsibleforpatient’spossessionsPatientsareinformedofthehospital’sresponsibilityPatient’spossessionsaresafeguardedwhenthehospitalassumesresponsibilityorwhenthepatientisunabletoassumeresponsibilityPFR.1.3PatientPossessionsThePFR.1.4PhysicalAssaultThereisaprocesstoprotectpatientsfromassaultThoseaddressedintheprocessare:Infants,Vulnerablechildren,ElderlyOthersunabletoprotectthemselvesIndividualswithoutidentificationareinvestigatedRemoteorisolatedareasaremonitoredPFR.1.4PhysicalAssaultTherePFR.1.5AppropriateProtectionLeadersidentifyvulnerablepatientgroupsThoseprotectedinclude:Children,disabledindividuals,elderlyOthersidentifiedbythehospitalStaffmembersunderstandtheirresponsibilitiesforprotectionPFR.1.5AppropriateProtectionPFR.1.6ConfidentialInformationPatientsareinformedabout:Howtheirinformationwillbekeptconfidentialandaboutlawsandregulationsthatrequirethereleaseand/orrequireconfidentialityofpatientinformationPatientsarerequestedtograntpermissiontoreleaseinformationnotcoveredbylawandregulationPFR.1.6ConfidentialInformatiPFR.2ParticipationinCarePoliciessupportandpromotepatientandfamilyparticipationincareprocessesPoliciesandproceduresaddresstherighttoseekasecondopinionwithoutfearofcompromisedcareStaffmembersaretrainedontheirroleinsupportingparticipationincareprocessesPFR.2ParticipationinCarePolPFR.2.1PatientInformationPatients&familiesunderstandhowandwhentheywillbetoldaboutmedicalconditionsandanyconfirmeddiagnosisplannedcareandtreatmentwhenconsentswillberequestedandtheprocessusedtheirrighttoparticipateincaredecisionsPFR.2.1PatientInformationPatPFR.2.1.1OutcomesofCarePatientsandfamiliesunderstandhowtheywillbetoldandwhowilltellthemoftheoutcomesofcareandtreatmenthowtheywillbetoldandwhowilltellthemofanyunanticipated

outcomesofcareandtreatment(outcomeoftreatmentincludingunanticipatedoutcome)PFR.2.1.1OutcomesofCarePatiPFR.2.2RighttoRefuseorDiscontinueCarePatientandfamilieswillunderstand:theirrightstorefuseordiscontinuecaretheconsequencesoftheirdecisionstheirresponsibilitiesrelatedtosuchdecisionsavailablecareandtreatmentalternativesPFR.2.2RighttoRefuseorDisPFR.2.3WithholdingResuscitation/WithdrawingLifeSupportHospitaldefinesitspositionHospital’spositionconformsto:Community’sreligiousandculturalnormsAnylegalorregulatoryrequirementsPoliciesguidepatientson:HowtomaketheirdecisionsknownHowtomodifydecisionsduringcarePolicies&proceduresguide:Hospital’sresponsetopatient’sdecisionsDocumentationaboutdecisionsTheethicalandlegalissuesrelatedtocarryingoutthepatient’swishesPFR.2.3WithholdingResuscitatPFR.2.4AssessmentofPainTheorganizationrespectsandsupportsthepatient’srighttoappropriateassessmentandmanagementofpainStaffunderstandthepersonal,cultural,andsocialinfluencesonthepatientsrightto:reportpainaccuratelyassessandmanagepainPFR.2.4AssessmentofPainThePFR.2.5EndofLifeCareHospitalstaffrecognizesthatdyingpatientshaveuniqueneedsStaffrespectstherightofdyingpatientstohavethoseuniqueneedsaddressedinthecareprocessPFR.2.5EndofLifeCareHospitPFR.3ComplaintsandConflictsPatientsareawareoftheirrighttovoiceacomplaintandtheprocesstodosoThehospitalhasandusesamechanismtoreview:complaintsdilemmasthatariseduringcarePPidentifyparticipantsintheprocesshowthepatientandfamilyparticipatePFR.3ComplaintsandConflictsPFR.4EducationofStaffStaffmembersunderstand:theirroleinidentifyingpatientandfamilyvaluesandbeliefshowthesevaluesandbeliefscanberespectedinthecareprocesstheirroleinprotectingpatientandfamilyrightsPFR.4EducationofStaffStaffPFR.5PatientsareInformedofRightsPatientsreceiveinformationabouttheirrightsinwritingThehospitalhasaprocesstoinformpatientsorfamiliesoftheirrightswhenwrittencommunicationisnoteffectiveorappropriateLanguageIlliteracyMedicalconditionPFR.5PatientsareInformedofPFR.6PatientsReceiveInformation

PolicyandprocedurecontainaclearlydefinedinformedconsentprocessPatientsgiveconsentconsistentlywithpolicyDesignatedstaffaretrainedconsistentlywithpolicyPFR.6PatientsReceiveInformaPFR.6.1AdequateInformationPatientsareinformedabout:theirconditionproposedproceduresandtreatmentsandwhoisauthorizedtoperformthempotentialbenefitsanddrawbacksandpossibleproblemsrelatedtorecoveryalternativestotheproposedtreatmentandresultsofpossiblenon–treatmentlikelihoodofsuccessoftreatmentsPatientsknowtheidentifyofthephysicianorpractitionerresponsiblefortheircarePFR.6.1AdequateInformationPaPFR.6.2OthersGivingConsentThehospitalhasaprocessforwhenotherscangrantinformedconsentTheprocessisconsistentwithlaw,culture,andcustomTheindividualgivingconsentisdocumentedinthepatient’srecordPFR.6.2OthersGivingConsentTPFR.6.3GeneralConsentIfGeneralConsentisobtainedatthetimeofadmissionorregistrationforthefirsttimeasanout-patient,then:thescopeofaGeneralConsentiscleartheGeneralConsentisdocumentedperhospitalpolicyHowever,thestandardsdonotrequireaGeneralConsentPFR.6.3GeneralConsentIfGenePFR.6.4RequiredInformedConsentsConsentisobtainedbefore:SurgicalorinvasiveproceduresAnesthesiaotherthanlocalModerate(“conscious”)anddeepsedationBloodandbloodproductsHigh-riskproceduresandtreatmentsRequireddocumentationinthemedicalrecord:IdentityoftheindividualprovidinginformationtopatientandfamilyPatient’ssignatureorarecordofverbalconsentPFR.6.4RequiredInformedConsPFR.6.4.1SpecificConsentsThehospitalhasalistofthoseoperations,procedures,andtreatmentsthatrequireaseparateconsentThelistisdevelopedcollaborativelybyphysiciansandothersthatprovidethetreatmentsandperformtheproceduresPFR.6.4.1SpecificConsentsThePFR.7AccesstoResearchPatientswhomaybenefitfromparticipatinginresearchareidentifiedandinformedabouthowtogainaccesstoresearchPatientsaskedtoparticipateareinformedabout:ExpectedbenefitsPotentialdiscomfortsandrisksAlternativesthatmighthelpthemProceduresthatmustbefollowedRefusaltoparticipateorwithdrawwillnotcompromisetheiraccesstoservicesRelevantonlyifresearchisdoneinthehospitalPFR.7AccesstoResearchPatienPFR.7.1ResearchPatientsareProtected

Patientsandfamiliesareinformedaboutthehospital’sprocessfor:ReviewingresearchprotocolsWeighingthebenefitsandrisksObtainingconsentWithdrawingfromparticipationPFR.7.1ResearchPatientsarePFR.8InformedConsentforResearchInformedconsentisobtainedwhenthepatientdecidestoparticipateConsentdecisionsaredocumented,datedTheindividualprovidingtheinformationisdocumentedinthepatient’srecordConsentisdocumentedinthemedicalrecordbysignatureofthepatientorrecordofverbalconsent

PFR.8InformedConsentforResPFR.9OversightofResearchTheorganizationhasacommitteeorothermechanismtooverseeresearch:Oversightincludes:AclearstatementofthepurposeofoversightactivitiesAreviewprocessAprocesstoweighrelativerisksandbenefitsProcessestoprovideconfidentialityandsecurityofresearchinformation

PFR.9OversightofResearchThePFR.10OrganDonationThehospitalsupportspatientandfamilychoicestodonateorgansandothertissueprovidesinformationtosupportthechoicePFR.10OrganDonationThehospiPFR.11Oversight

Policyandprocedureguide:theprocurementanddonationprocessthetransplantationprocessStaffistrained:inthepolicyintheissuesandconcernsrelatedtoorgandonationandtheavailabilityoftransplantsThehospitalcooperateswiththerelevantorganizationsandagenciesinthecommunitytorespectandimplementchoicestodonatePFR.11OversightPolicyandprThankYouNextPresentationThankYouNextPresentationAssessmentofPatients

(AOP)79AssessmentofPatients(AOP)7AOP–ThreeAreasofFocusCollectingandAnalyzingPatientDataandInformationLaboratoryServicesRadiologyandDiagnosticImagingServicesAOP–ThreeAreasofFocusCollAOP.1–AOP.1.1

AssessmentProcessAOP.1HospitalPP:definetheassessmentinformationtobeobtainedforinpatientsoutpatientsidentifytheinformationtobedocumentedfortheassessmentsAOP.1.1Thescopeandcontentofassessmentsaredefinedinpolicies:ForeachclinicaldisciplineForinpatientandoutpatientsettingsAOP.1–AOP.1.1

AssessmentPrAOP.1.2InitialAssessmentInpatientsandoutpatientshaveaninitialassessmentthatmeetshospitalpolicy(NotethatbyAOP.1and1.1,inpatientandoutpatientassessmentsmaybeverydifferent)Initialassessmentincludes,accordingtohospitalpolicy:AmedicalassessmentincludingahealthhistoryandphysicalexaminationApsychologicalassessmentappropriatetoneedsSocialandeconomicasappropriatetoneedsContinuedonnextslideAOP.1.2InitialAssessmentInpaAOP.1.2InitialAssessment

Theinitialassessmentresultsin:UnderstandinganypreviouscareandthecarethepatientiscurrentlyseekingSelectingthebestsettingforthecareAninitialdiagnosisAOP.1.2InitialAssessment

TheAOP.1.3Patient’sNeedsIdentifiedTheinitialassessmentresultsin:Identificationofpatient’smedicalneedsIdentificationofpatient’snursingneedsMedicalneedsareidentifiedbasedonthedocumentedH&PandotherrequiredhospitalassessmentsNursingneedsareidentifiedbasedonthenursingassessment,themedicalassessmentandotherrequiredhospitalassessmentsAOP.1.3Patient’sNeedsIdentiAOP.1.3.1AssessmentofEmergencyPatientsEmergencypatientshave:MedicalassessmentappropriatetotheirneedsandconditionNursingassessmentappropriatetotheirneedsandconditionIfemergencysurgeryisperformed,thefollowingarerecordedbeforetheoperation:AbriefassessmentnoteApreoperativediagnosisAOP.1.3.1AssessmentofEmergeAOP.1.4–AOP.1.4.1TimeFramesAssessmenttimeframesareestablishedforallsettingsandservicesTheinitialmedicalandnursingassessmentsareconductedwithinthefirst24hoursorearlierasindicatedbythepatient’sconditionorhospitalpolicy(AOP.1.4.1)AssessmentsarecompletedintheestablishedtimeframesAssessmentsfromoutsidetheorganizationarereviewed/verifiedatthetimeofadmissiontoinpatientstatusAOP.1.4–AOP.1.4.1TimeFrameAOP.1.4.1AssessmentsPerformedBeforeAdmissionForanyassessmentconductedmorethan30dayspriorto:admissiontoinpatientstatusoranoutpatientprocedure

themedicalhistoryhasbeenupdatedandthephysicalexaminationrepeatedForanyassessmentlessthan30daysold,anysignificantchangesinthepatient’sconditionarenotedatthetimeofadmissiontoinpatientstatusAOP.1.4.1AssessmentsPerformeAOP.1.5AssessmentsareAvailableAssessmentsaredocumentedinthepatient’smedicalrecordIndividualscaringforthepatientcanfindandretrieveassessmentsasneededMedicalandnursingassessmentsaredocumentedwithin24hoursofadmissionForotherthanmedicalandnursingassessments,therecanbeasummarynoteinthepatient’srecord,withafullerdescriptionintheconcerneddepartmentaslongasthereisaccesstothem(seeIntentStatement)

AOP.1.5AssessmentsareAvailaAOP.1.5.1AssessmentsbeforeAnesthesiaorSurgeryMedicalassessmentisperformedpriortosurgeryMedicalassessmentisdocumentedpriortosurgeryAOP.1.5.1AssessmentsbeforeAAOP.1.6NutritionalandFunctionalScreeningQualifiedindividualsdevelopcriteriatoidentifypatientswhorequirefurthernutritionaland/orfunctionalassessmentPatientsarescreenedfornutritionalriskand/orfunctionalriskaspartoftheinitialassessmentPatientsidentifiedforadditionalassessmentbasedonthecriteriathatidentifiesadditionalneeds,receiveadditionalassessmentsfornutritionaland/orfunctionalneeds(Functionalrisk