Joint Commission Review

Tuesday, April 16, 2013 at 4:24:30 PM

Despite the positive overall impression, there are still some plans of correction and monitoring to be done as a result of the recent Joint Commission survey relating to:
o Dating and signing of phone orders within 48 hours
o Dating and timing of notes and orders.
o Post-procedure notes need to be done immediately, and should include each procedure finding, specimens removed, estimated blood loss, and post-operative diagnosis.
o Histories and physicals cannot be more than 30 days old and updated prior to procedure.
o Pain medication orders require parameters for administration.
o The provider is responsible for the contents of the restraint order, to include indication, type, and alternatives considered. The policy has been changed to require daily renewals (was 24 hours) to allow the physician to renew when doing rounds. If the Resident does the DNR order, it must be countersigned.
o Illegibility of notes and signatures was found in many areas and will be a focus of activities going forward. Physicians with legibility issues are asked to block print orders and alongside signatures to insure understanding.
Your continued diligence in these areas would be much appreciated.

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