Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and...

StorkTJC (The Joint Commission) Readiness Scavenger Hunt

Table of Contents

• Demographics• Race and ethnicity• Preferred language

• Education• Learning needs• Patient education

• Nursing Assessments• Initial/Ongoing• Nutritional screen• Fall risk• Abuse/Neglect• Suicide Risk• Pain Assessment/Reassessment• Advance Directives

• Physician Documentation• History and physical• Consult notes • Authentication of orders

• Medication • Medication reconciliation on admission, discharge or transfer• Clarity of orders

• Procedural Documentation• Informed consent• Pre-anesthesia assessment• Immediate pre-induction assessment• Pre-procedure checklist• Timeout• Immediate post-op note• Post-anesthesia assessment

• Ancillary Documentation• Discharge planning• Respiratory therapy• PT/OT• Wound Consult• Social Work• Dietary

• Restraint Documentation• Orders• Monitoring• Inclusion in plan of care

Table of Contents (cont’d)

Demographics: Race and EthnicityGrease board > Patient Chart > Patient Name > Contact Information tab/Clinical Information tab

Demographics: Preferred Language

Patient Chart > Patient Header > Language: field

Education: Learning Needs and Patient Education

Patient chart > Education Activity > Education tabPatient Chart > Education Activity >

Assessment Tab

Nursing Assessments: Nutritional Screening, Fall Risk, Abuse/Neglect, Pain, Advance Directives

Patient Chart > Navigators Activity > Advance Directives, Nutrition, Psychosocial (Abuse/Neglect), Fall Risk

Nursing Assessments: Initial/Ongoing, Suicide Risk

Patient Chart, Flowsheet Activity > Assessment or All Doc tab/Suicide Risk Assessment (may need to be wrenched in)

Nursing Assessments: Pain Assessment/Reassessment

Patient Chart, Flowsheet Activity > All Doc tab > Pain

Provider Documentation: H&P, Consult Notes

Patient Chart > Notes Activity > Sort by Type (H&P or consult)

Provider Documentation: Authentication of OrdersPatient Chart > Orders Activity > Order History

Medication: Med Rec on Admission/Transfer/Discharge

Patient Chart > Navigators > Triage/Transfer/Discharge tab > Med Rec Status

Medication: Clarity of Orders

Patient Chart > MAR Activity > Click in the medication box and it will show all detailsAlso can use the Show All Details Filter and the details of all MAR orders will expand

Procedural Documentation: Informed Consent, Pre-Anesthesia Assessment, Immediate Pre-Induction Assessment, Pre-Procedure Checklist, Timeout, Post-Anesthesia Assessment

Patient Chart > Chart Review > Procedures tab > Click on procedure note to open detail of the procedure

Procedural Documentation: Immediate Post-Op Note

Patient Chart > Chart Review > Procedures tab > Click on procedure note to open detail

Ancillary Documentation

FYI: Clicking the “Type” header will sort notes by type and make finding notes by ancillary departments faster

Patient Chart > Chart Review Activity > Notes tab > sort by type to find ancillary department name