Closed Medical Record Review

Sub-Std
Sub-Standard

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

AVG
(10)
No.

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)
The hospital implements a policy and procedure that defines the assessment process and its scope and content for
PC.6.2 all categories of patients (adults, geriatrics, pediatrics, pregnant women, trauma patients and others).
The hospital implements a policy and procedure that defines the assessment process and its scope and content for
PC.6.3 all disciplines (physicians, nurses, physiotherapists, social service and others).
PC.6.4 The policy defines the staff categories qualified by license, certification, and experience to assess patients.
PC.8.1 The hospital has criteria to identify patients requiring discharge planning before or upon admission
The hospital implements a policy that defines the time frame for completing the medical, nursing, and other
PC.9.1 assessments required for different care settings and services.
Each patient undergoes an initial medical assessment that includes a health history and physical examination,
covering the following:
PC.10.1 PC.10.1.1 Main complaint.
PC.10.1.2 Details of the present illness.
PC.10.1.3 Systems review.
PC.10.1.4 Past history including previous admissions and surgeries.
PC.10.1.5 Allergies and prior adverse drug reactions.
PC.10.1.6 Drug history.
PC.10.1.7 Family history.
PC.10.1.8 Psycho-social history.
PC.10.1.9 Economic factors.
PC.10.1.10 Pain (screening followed by assessment if required).
PC.10.1.11 Risk for fall (screening followed by assessment if required).
PC.10.1.12 Physical status and functionality (screening followed by assessment if required).
PC.10.1.13 Complete physical examination.
PC.10.1.14 Diagnostic test(s) as indicated by the patient’s condition.
PC.10.1.15 Need for additional or specialized assessment as indicated by the patient’s
PC.10.1.16 Need for discharge planning as indicated by the patient’s condition.
PC.10.1.17 Provisional diagnosis.
Sub-Std

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN
Sub-Standard

AVG
(10)
(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)
No.
Medical assessment is performed by the most responsible physician or a member of the team who is qualified by
PC.10.3 license, certification, and experience.
PC.10.6 The medical assessment is documented in the patient’s medical record.
All patients are reassessed at appropriate intervals to determine:
PC.17.1.1 Response to treatment.
PC.17.1 PC.17.1.2 Compliance with treatment.
PC.17.1.3 Complications and side effects.
PC.17.1.4 Plan for continued treatment or completion of treatment.
Nursing reassessment must be performed on every shift with a frequency dictated by the patient’s condition,
PC.17.3 response to treatment, and physician’s order.
The hospital defines situations where re-assessments are performed more infrequently (e.g., long stay patients
PC.17.5 mainly requiring a nursing care).
When required, the hospital provides referral and transfer services to other facility that can provide palliative care (e.g., bed
PC.24.5
or resources availability).
When applicable, the hospital provides or arrange for a nursing home care (e.g., inability to refer, or patient/family
PC.24.6
wish).
Only physicians order blood and in accordance with a policy clarifying when blood and blood products may be
PC.25.2 ordered.
The physician obtains informed consent for transfusion of blood and blood products. Elements of patient consent include:

PC.25.3 PC.25.3.1 Description of the transfusion process.

PC.25.3.2 Identification of the risks and benefits of the transfusion.
PC.25.3.3 Identification of alternatives including the consequences of refusing the treatment.
PC.25.3.4 Giving the opportunity to ask questions.
PC.25.3.5 Giving the right to accept or refuse the transfusion.
Two staff members verify the patient’s identity prior to blood drawing for cross match and prior to the administration of
PC.25.4
blood.
PC.25.6 Blood is transfused according to accepted transfusion practices from recognized professional organizations.
PC.25.8 Patients receiving blood are closely monitored.
PC.25.9 Transfusion reactions are reported and analyzed for preventive and corrective actions.
Two staff members verify the patient’s identity prior to blood drawing for cross match and prior to the administration of
PC.25.4
blood.
Sub-Std
Sub-Standard
No.

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

AVG
(10)
(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)
PC.33.3 Activities of the rapid response teams are documented.
PC.38.1 The patient and the family are involved in the discharge process with clear follow up instructions.
PC.38.2 Discharge is based on the patient’s condition and relevant policies or criteria.
PC.38.3 Patients' needs after discharge are assessed as early in the care process as possible.
PC.38.4 The discharge process identifies the post-service needs and supports continuity of care after discharge.
PC.38.5 The post-service needs are communicated to relevant staff members.
PC.38.6 Staff members ensure coordination with various departments involved in the discharge process.
Whenever required, staff members ensure coordination with outside organizations and post-service providers as
PC.38.7
appropriate to the patient's needs.

PC.38.8 Staff members ensure that all patients’ needs are met prior to discharge.
Transfer is based on the patient's health needs for continuing care and the resources available for both referring
PC.39.2 and receiving organizations.

The most responsible physician determines the need for transfer, the most suitable time for transfer, resources required
PC.39.3 during transfer, and whether the receiving organization can meet the patient’s health and supportive
needs.

There is a written acceptance for transfer of responsibility for the patient's care by the receiving provider/organization.
PC.39.5

The hospital communicates with all potential receiving organizations and necessary arrangements are made
PC.39.6
whenever applicable.

PC.40.1 The most responsible physician assesses the transportation needs of the patient according to his condition.
PC.40.2 Transportation needs of the patient are communicated to the relevant staff.
PC.40.4 The most responsible physician ensures that all patient’s health needs during transportation are met.
PC.40.5 Adequate equipment and supplies are available during transportation.
PC.40.6 A qualified staff member accompanies the patient during transportation.
PC.40.7 The patient is monitored as appropriate during transfer.
PC.40.8 Handover is completed to staff at the receiving organization
 Sub-Std

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

MRN

AVG
(10)
Sub-Standard

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)
No.
A summary of the patient's condition (e.g., a discharge summary) is sent with the patient to the receiving
organization. The summary includes:
PC.41.1.1 Reason for the patient’s admission.
PC.41.1.2 Patient diagnosis.
PC.41.1 Brief summary of hospitalization and services provided (therapies, consultations, procedures to
PC.41.1.3
date).
PC.41.1.4 Medication list and time of last dose(s) given.
PC.41.1.5 Patient condition and physical status at the time of transfer.
PC.41.1.6 Rationale for transfer.
PC.41.1.7 Results of the patient’s diagnostic investigations (e.g., laboratory and radiology).
PC.42.1 Whenever required, follow up appointments are arranged for the patient prior to discharge.
PC.42.3 The hospital provides a discharge summary for all inpatients upon discharge.
PC.42.4 A copy of the discharge summary is kept in the patient’s medical record.
PC.42.5 A copy of the discharge summary is given to the patient.
PC.42.7 The discharge summary is complete and typewritten.
The scope and content of the nursing assessment is defined in hospital policies and may include:
NR.10.2.1 History of the patient’s main complaint.
NR.10.2.2 Drug allergies.
NR.10.2.3 Physical condition.
NR.10.2 NR.10.2.4 Psychosocial status.
NR.10.2.5 Pain assessment.
NR.10.2.6 Nutritional Status.
NR.10.2.7 Discharge planning.
NR.10.2.8 Skin assessment.
NR.10.2.9 Fall risk assessment.
QM.14.5 Patients receive response when involved in significant incidents with documentation in the medical records.
QM.18.2 The process consists of three phases: verification, site marking, and time out.
A pre-procedure verification of the patient information is carried out including the patient’s identity, consent, full
QM.18.3 details of the procedure, laboratory tests and images, and any implant or prosthesis.
The surgical/procedural site is marked before conducting the surgery/procedure.
The site is marked especially in bilateral organs and multiple structures (e.g. fingers, toes, and spine).
QM.18.4.1
QM.18.4 QM.18.4.2 The site is marked by the individual who will perform the procedure.
QM.18.4.3 The patient is involved in the marking process.
QM.18.4.4 The marking method is consistent throughout the hospital.
QM.18.4.5 The mark is visible after the patient is prepped and draped.

Open Medical Record Review

 The initial assessment aims to identify the general patient’s medical and nursing needs and a provisional diagnosis
PC.6.5
so that care and treatment can be initiated.
 The hospital implements a policy that defines the criteria and process for screening patients for pain, functional
PC.7.1
limitations including risk for fall, and malnutrition.
PC.7.3 When pain is present from the initial screening, the patient receives a comprehensive pain assessment.
PC.7.4 Patients with functional impairment are referred for functional assessment.
PC.7.5 Patients identified as malnourished or at risk for malnutrition are referred for a nutritional assessment.
PC.8.2 A proposed discharge date is set soon after admission.
Medical and nursing assessments are completed and documented within the first 24 hours of admission for routine
PC.9.2
elective cases.
Medical and nursing assessments are completed and documented earlier whenever indicated by the patient’s
PC.9.3
condition and the hospital policy.
Assessments completed within 30 days prior to admission or an outpatient visit can be used with a documented update of any significant changes.
PC.9.4

PC.9.5 Assessments completed more than 30 days prior to admission or an outpatient visit must be repeated.
Medical and nursing assessments are completed and documented for all patients prior to surgery, anesthesia or invasive procedures.
PC.9.6

The most responsible physician ensures all patients under his care have a complete medical assessment with all
PC.10.2
diagnostic tests and referrals as required to reach a final diagnosis.
Diagnostic tests (e.g., laboratory and radiology) are appropriately and timely ordered to aid in reaching a final
PC.10.5
diagnosis.
PC.11.1 The nursing assessment is performed by a staff nurse.
PC.11.3 The nursing assessment must be timely and complete.
PC.11.4 The nursing assessment is documented in the patient’s medical record.
PC.12.1 There are criteria implemented to identify patient groups who need additional or specialized assessments.
Additional assessment includes, but is not limited to, the following categories:
PC.12.2.1 Patients in severe or chronic pain.
PC.12.2.2 Children.
PC.12.2.3 Frail and elderly.
PC.12.2
PC.12.2.4 Suspected victims of abuse, neglect, and domestic violence.
PC.12.2.5 Drug abuse.
PC.12.2.6 Psychiatric disorders.
PC.12.2.7 Women in labor.
PC.12.2.8 Terminally ill and dying patients.

PC.12.3 Specialized assessment includes patients with dental, hearing, eye or speech defects.
When additional or specialized assessments are required, they are completed and documented in the patient’s
PC.12.4 medical record.

PC.14.1 The hospital addresses pain (acute/chronic) assessment and management as a patient’s right.
 PC.14.3 Patients in pain receive pain assessment and management according to the policy.
PC.14.4 The process of pain assessment and management is documented in the patient’s medical record.
Each patient has one qualified physician responsible for the overall care rendered to that patient and is referred to
PC.15.1
as the most responsible physician (MRP).

The most responsible physician provides the principal care plan and coordinates when required for additional
PC.15.4
plans of other healthcare providers.

Transfer of patient responsibility from one physician to another is guided by a hospital policy and is documented
PC.15.5
in the patient’s medical record.

PC.16.1 The plan of care is developed through a collaborative approach between the healthcare team(s), patient, and family.
PC.16.2 The plan of care is based on the assessment findings and aimed to meet all patients’ needs.
PC.16.3 The patient and family are involved in developing the plan of care.
PC.16.4 The plan of care contains the measurable goals/desired outcomes towards discharge.
The plan of care is completed within 24 hours of admission or earlier based on the patient’s condition and needs.
PC.16.5
(Nursing plan of care is completed whenever possible before the end of the shift).

PC.16.6 The plan of care is reviewed by the most responsible physician on a daily basis.
The plan of care is modified as appropriate upon any significant change in the patient’s condition or when new
PC.16.7
treatments are added or discontinued.

PC.16.8 The plan of care includes a provisional date of discharge set within 24 hours of admission.
PC.16.9 The plan of care is documented in the patient’s medical record.
Medical reassessment must be performed at least once daily, including weekends and holidays, and in response
PC.17.2 to any significant change in the patient’s condition.

PC.17.4 Reassessments are documented in the patient’s medical record.

PC.18.3 Clinical practice guidelines, pathways, and protocols are documented in the patient’s medical record.
PC.19.1 The hospital implements a policy for the assessment and management of patients undergoing invasive procedures.
The policy defines all essential requirements that must be documented in the patient’s medical record including,
but are not limited to:

PC.19.2.1 Date and time of the procedure.

Name, designation and signature of the physician performing the procedure and the names of all assistants.
PC.19.2 PC.19.2.2

PC.19.2.3 Location of the procedure.

PC.19.2.4 Nature and indication of the procedure.
PC.19.2.5 Any anesthesia or analgesia used with dosage and type.
PC.19.2.6 Patient monitoring.
PC.19.2.7 Procedure outcome.
 PC.19.2.8 Complications.
PC.19.2.9 Laboratory specimens.
PC.19.2.10 Specific post procedural orders.
PC.19.3 Invasive procedures are documented in the patient’s medical record (or in an appropriate form) as per the policy.
Information about the patient's care and response to treatment is shared between medical, nursing, and other care providers (e.g., patient rounds,
PC.20.1
multidisciplinary teams, case management for patients requiring complex care).
PC.21.1 There is a physician’s order form where physicians document all orders relating to the patient car
PC.21.2 Only physicians are allowed to write in the physician order form (except for telephone and verbal orders).
PC.21.3 Physician orders include medications and non-medication orders.
PC.21.4 All orders are acknowledged by the nurse in charge of the patient, dated and timed.
Medical and other relevant staff who are on call respond promptly to incoming consultations and care related
PC.22.4
requests.
PC.23.1 There is a nursing pre-operative checklist that is completed by the assigned nurse.
PC.23.2 The checklist uses the "Yes", "No" and "Not Applicable" format.
PC.23.3 Patients are not transferred to the operating room if the checklist is not completed except in dire emergencies.
The assigned nurse endorses all the findings of the pre-operative checklist to the receiving nurse in the operating
PC.23.4
room.
The receiving nurse in the operating room reviews all the findings of the pre-operative checklist with the assigned
PC.23.5
nurse and confirms in writing.
The nursing pre-operative checklist contains the following elements as a minimum:
PC.23.6.1 The nursing pre-operative checklist contains the following elements as a minimum:
PC.23.6.2 Evidence of completed relevant consents.
PC.23.6.3 Evidence of completed history and physical examination by medical and nursing staff.
PC.23.6.4 Evidence of site marking.
PC.23.6 PC.23.6.5 Availability of results of requested investigations.
PC.23.6.6 Availability of requested blood or blood products.
Evidence of removal of dentures and loose objects such as eye lenses, eyeglasses, and removable
PC.23.6.7
nails.
PC.23.6.8 Evidence of removal of jewelry and patient's valuables.
The hospital assesses and responds to the unique needs of end of life patients, including psychological, spiritual,
PC.24.1
social, and cultural assessment.
The hospital provides an effective palliative care for terminally ill patients (e.g., management of pain and
PC.24.2
management of other distressing symptoms).
PC.24.3 Family members are involved in care decisions.
PC.24.4 Family members are educated on how to care for their patient.
PC.26.1 Patients are screened for the risk of developing venous thromboembolism.
PC.26.2 Patients at risk receive prophylaxis according to current evidence-based practice.
 The need for psychiatric care and choice of modality are based on sound clinical principles and a thorough clinical
PC.27.3
evaluation of medical condition and co-morbidities.
PC.29.3 Patients are restrained only after an order by the most responsible physician or designee.
PC.29.4 The restraint order should be renewed at least every 24 hours.
PC.29.5 Patients are restrained as described in the relevant policy.
The most responsible physician assesses and decides on the indication, the most suitable type, and the time
PC.30.1
required for applying restraints.
The most responsible physician performs periodic assessment and reassessment as dictated by the patient’s
PC.30.2
condition (particularly, blood circulation to the limbs restrained).
PC.30.6 Nursing staff provide periodic monitoring of the restrained patient.
PC.30.7 Patients are reassessed on a frequent basis (at least hourly and as appropriate).
PC.30.8 Appropriate interventions are performed when the patient’s circulation is being impaired.
PC.34.4 Patient’s medical record reflects the use of these policies and plans.
The consulting physician completes a consultation request that defines:
PC.36.1.1 Date and time of consultation.
PC.36.1.2 Name and designation of consulting physician.
PC.36.1 PC.36.1.3 Name and designation of consulted physician.
Urgency of consultation (24 hours for routine inpatient consults and one hour or less for emergency cases).
PC.36.1.4

PC.36.1.5 Case summary.

PC.36.1.6 Rationale for consultation.
The consulted physician indicates in writing:
PC.36.2.1 Date and time of consultation visit.
PC.36.2
PC.36.2.2 Name and designation.
PC.36.2.3 Opinion and recommendations, including the need to transfer the patient under his name.
The consulting physician approves and follows up the implementation of the plan of care as set by the consulted
PC.36.3
physician.
The most responsible physician assesses the need for transfer and matches the condition of the patient with
PC.37.1 admission criteria of the unit.
Verbal or written agreement as received from the receiving unit is documented in the patient’s medical record,
PC.37.2
including the name of the receiving physician
PC.37.3 The most responsible physician assesses the transfer requirements, both staff and equipment.
Summary of the patient medical and nursing assessment findings including reason for transfer, diagnoses, clinical
PC.37.4
findings, and current medications is available in the patient’s medical record before transfer.
PC.37.5 The physician and the nurse at the receiving unit assess the patient at arrival to ensure safe and smooth handover.