- Coordination of care - Daily progress notes by attending physicians should reflect knowledge of clinical observations and treatment plan previously documented by residents, physician assistants, and nurse practitioners. Residents should link their notes with the attending’s note (“Case discussed with the attending, Dr. _____.”)
- Supervision - Resident supervision must be clearly documented by the attending or the resident in the progress notes.
- Post op notes - A post op note must be entered in the chart immediately after surgery and the operative report must be dictated within 24 hours.
- All employees and medical staff must be cognizant of patient privacy issues. Bed curtains should be used in patient rooms and patient information should not be discussed in public places.
- Informed consent must be obtained and must include risks, benefits, and alternatives. Consents must be signed and witnessed.
- Physicians must write orders for every episode of restraints. Non violent restraint orders must be renewed every 24 hours. Violent or self destructive orders must be renewed every 4 hours for adults, ever 2 hours for children age 9 to 17 and every 1 hour on children under the age of 9. A physician must conduct a “face to face” assessment of the patient no longer than 1 hour after the application of restraints. This assessment must be documented in the medical record.
- Physicians must document the rationale for the use of restraints, type of restraint and the specific time period for their use.
- Know the Joint Commission National Patient Safety Goals (please note that you should be particularly comfortable speaking about those related to your area of practice)
Each year the Joint Commission issues a set of National Patient Safety Goals. All accredited hospitals are required to comply with these goals. The goals are selected based on sentinel events that have been submitted to the Joint Commission and reviewed by the Sentinel Event Advisory Group. These goals address safety issues that have resulted in a significant patient harm.
Use at least two patient identifiers (ex., patient’s name date of birth) whenever administering medications or blood products; taking blood
March 17, 2009