Generic Closed Record Review Tool
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GENERIC CLOSED RECORD REVIEW TOOL
MR#______DC Date:______Type of Review:______Standard / Number / Question / Y / N / NA
1. ADVANCE DIRECTIVE
RI.01.05.01RC.02.01.01 / 1.a / Does the patient have an Advance Directive?
1.b / If yes, is a copy on the chart?
1.c / If no, was patient asked if wanted info on Advance Directive?
1.d / If yes and there is no copy on the chart, is the intent of the advance directive on the chart?
2. CONSENT
RI.01.03.01
RC.02.01.01 / 2.a. / Is there a consent for medical treatment, which includes a discussion of the following elements:
-nature of proposed care, treatment, services, medications, interventions, or procedures
-likelihood of achieving goals
-reasonable alternatives
-relevant risks, benefits, and side effects related to alternatives, including the possible results of not receiving care, treatment, and services
-When indicated, any limitations on the confidentiality of information learned from or about the patient?
RI.01.03.01
RC.02.01.01 / 2.b / If applicable, was Informed Consent completed and dated prior to procedure?
3. NURSING ASSESSMENT
PC.01.02.01
EP4 / 3.a / Physical assessment, as appropriate
3.b / Psychological assessment, as appropriate
3.c / Social assessment, as appropriate
3.d / A nutritional screening, when warranted by the patients’ needs or condition, is completed within no more than 24 hours of inpatient admission.
3.e / A functional status screening, when warranted by the patients’ needs or condition, is completed within no more than 24 hours of inpatient admission.
3.f / Was there timely follow-up by the relevant discipline? If not, which discipline?______
3.g / A registered nurse completes a nursing assessment within 24 hours of inpatient admission. Dated/timed/signed
3.h / Was there an assessment of abuse and neglect, and if applicable, referred appropriately?
Standard / Number Question Y N NA
4. HISTORY & PHYSICAL
PC.01.02.03
EP2 / 4.a / A medical history and physical examination is completed within no more than 24 hours of inpatient admission. Check date/time of dictation.
4.b / If older than 1 day (must be less than 30 days), does H&P have an update note/date/signature within 24 hours?
4.c
Content of H & P includes / 1) Chief Complaint
2) History of Present Illness
3) Past Medical History
4) Family and Social History
5) Social History
6) Review of Body Systems
7) Impression/Conclusion
8) Report of Relevant Physical Findings
9) Plan
10) Summary of Psychosocial Needs, age appropriate
PC.01.02.07 / 5. PAIN ASSESSMENT & RE-ASSESSMENTS – NA if this patient had no pain
5a. / Was there an initial pain assessment using pain scale?
5b. / If pain med was given, was reassessment documented in time?
5c. / If multiple prn pain meds, was policy followed?
5d. / Were there any range orders:
PC.01.02.03 / 6 / Are there documented updates to the patient’s condition since the admission assessment(s)?
6.a / Progress note by physician every 24 hours.
6.b / Nurse assessment of patient every shift.
PC.01.02.01 / 7. / PLAN OF CARE
PC.01.02.03 / 7.a / Is the plan congruent with nursing’s assessment, H&P?
PC.01.02.09 / 7.b / Is the plan reflective of any Dietary, PT, RT, OT, etc treatment plans, with assessments and reassessments per policy and pt need?
PC.01.03.01 / 7.c / Are findings from assessments integrated into the care planning process?
PC.02.01.05 / 7.d / Is there evidence of interdisciplinary planning as appropriate?
Standard / Number / Question / Y / N / NA
NPSG.09.02.01 / 8.a / Is fall risk assessment done as per policy?
8.b / Were medication changes considered in the fall status?
8.c / Was this pts fall risk assessed and implementations followed based on assessment?
9. / MEDICATIONS
NPSG.08.01.01
NPSG.08.02.01
NPSG.08.03.01
NPSG.08.04.01 / Is the med reconciliation form complete and signed?
9.a / by nursing?
9.b / by practitioner?
MM.04.01.01 / 10.a / Are medication orders complete, i.e. dose, route, frequency, name, reason on chart?
10.b / Were incomplete or unclear orders clarified as per policy?
NPSG.02.01.01 / 10.c / Were any Do Not Use Abbreviations found (include preprinted forms)?
10.d
10.d.1 / QD,qd x #______
10.d.2 / U,u x #______
10.d.3 / IU x #______
10.d.4 / QOD, qod x #______
10.d.5 / Trailing zero (x.0mg) x #______
10.d.6 / Lack of leading zero (.x mg) x #______
10.d.7 / MS x #______
10.d.8 / MS04 x #______
10.d.9 / MgSO4 x #______
Note: Apply to all orders – all medication-related documentation and pre-printed forms
MM.04.01.01 / 11.a / Areallergies listed and congruent? Possible form to check: nursing assessment/h&p/med rec./T-sheet/MAR.
12.a / Did physician orders have “reason why” for prn orders?
12.b / Was the “reason why” for prn orders transcribed to MAR?
12.c / Was the nursing process for reviewing orders for correctness followed?
13.a / Did the nurse administer prn meds per “reason why”?
Especially check Tylenol (“fever”, “pain”, or “fever or pain”
13.b / Was the automatic stop policy followed?
14. AUTHENTICATION
RC.01.01.01
RC.01.02.01
RC.01.03.01
RC.02.01.03 / The author authenticates either by written signature, electronic signature, or computer key or rubber stamp the following (no later than 30 days past discharge):
14.a / The history and physical examination
14.b / Operative reports
14.c / Consultations
14.d / Discharge Summary
Standard / Number / Question / Y / N / NA
15.CHECK CONSULTS
15.a / Does each order for a consult have a corresponding consult report?
15.b / Is the reason for each consult specified?
PC.02.03.01
EP1 / 16. EDUCATION
PC.02.03.01
EP10 / 16.a / The assessment of learning needs addresses cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication as appropriate.
As appropriate to the patient’s condition and assessed needs and the hospital’s scope of services, the patient is educated about the following:
16.b / The plan for care, treatment, and services
16.c / Basic health practices and safety
16.d / The safe and effective use of medications (including use of PCA is applicable)
16.e / Nutrition interventions, modified diets, or oral health
16.f / Safe and effective use of medical equipment or supplies when provided by the hospital
16.g / Understanding pain, the risk for pain, the importance of effective pain management, the pain assessment process, and methods of pain management
16.h / Habilitation or rehabilitation techniques to help them reach maximum independence possible.
PC.02.03.01
EP5 / 16.i / Education is coordinated among the disciplines providing care, treatment, and services
PC.02.03.01
EP25 / 16.j / Comprehension is evaluated
PC.02.02.07
EP1 / 16.k / The hospital addresses the specific academic educational needs of children and youth
16.l / When indicated, the patient is educated about how to obtain further care, treatment and services to meet his or her identified needs
17. DISCHARGE INFORMATION
PC.04.01.03
EP4 / 17.a / When indicated and before discharge, the hospital arranges for or helps the family arrange for services needed to meet the patient’s needs after discharge
Standard / Number / Question / Y / N / NA
PC.04.01.05
EP8 / 17.b / Written discharge instructions in a form the patient can understand are given to the patient and/or those responsible for providing continuing care including medication
PC.04.02.01
EP1 / 17.c / The hospital communicates appropriate information to any organization or provider to which the patient is transferred or discharged. i.e. discharge instructions sent/faxed to next provider
PC.04.02.01
EP1 / 17.d / The information shared includes the following, as appropriate to the care, treatment, and services provided:
17.d.1 / The reason for transfer or discharge
17.d.2 / The patient’s physical and psychosocial status
17.d.3 / A summary of care, treatment, and services provided and progress toward goals
17.d.4 / Community resources or referrals provided to the patient
17.d.5 / Discharge meds are identified on discharge instructions
17.d.6 / If CHF patient, heart failure discharge instructions were given
RC.01.01.01
EP1,4-13 / 17.e / A concise discharge summary providing information to other caregivers and facilitating continuity of care includes the following:
17.e.1 / The reason for hospitalization and find diagnoses
17.e.2 / Significant findings
17.e.3 / Procedures performed and care, treatment and services provided
17.e.4 / The patient’s condition at discharge
17.e.5 / Information provided to the patient and family, as appropriate
17.e.6 / Patients discharge medications including dose, route frequency
RC.02.01.01
EP21 / 18. / EMERGENCY -
Medical records of patients who have received emergency care, treatment, and services contain the following information:
18.a / Times and means of arrival
18.b / Whether the patient left against medical advice
The conclusions at termination of treatment, including:
18.c / - final disposition
18.d / - condition
18.e / - instructions for follow-up care, treatment and services
18.f / A copy of the record was sent to the practitioner or medical organization providing follow-up care, treatment and services.
Standard / Number / Question / Y / N / NA
PC.04.02.01 / 19. / The hospital communicates appropriate information to any organization or provider to which the patient is transferred or discharged.
The information shared includes the following, as appropriate to the care, treatment, and services provided:
19.a / The reason for transfer or discharge
19.b / The patient’s physical and psychosocial status
19.c / A summary of care, treatment, and services provided and progress toward goals
19.d / Community resources or referrals provided to the patient
NPSG.02.03.01 / 20. / Critical Test Results
Is there evidence that any lab, x-ray or other critical test results were called per policy and procedure?
20.a / By department where test was done?
20.b / By receiving department to practitioner?
20.c / Timeframe not to exceed total of 20 minutes from time done to practitioner notified
20.d / All parties involved are identified by name/initials or other unique #?
Generic Closed Record Review Tool
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Additional Standards for Specific Patient PopulationsOPERATIVE/OTHER HIGH RISK PROCEDURES
Standard / Number / Question / Y / N / NA
IM.02.01.03
EP2 / 21 / The licensed independent practitioner (responsible for the patient) records the provisional diagnosis before the operative or other high-risk procedures
RI.01.03.01
EP11 / 21.a / A complete informed consent process includes a discussion of the following elements:
Potential benefits, risks or side effects, including potential problems that might occur during to recuperation
PC.03.01.01 / 22.The following must occur before the operative and other procedures or the administration of moderate or deep sedation or anesthesia:
22.a / A pre-sedation or pre-anesthesia assessment is conducted
22.b / Before sedating or anesthetizing a patient, a licensed independent practitioner with appropriate clinical privileges plans or concurs with the planned anesthesia.
22.c / Is the pre-sedation assessment complete and performed by the physician or anesthesia staff.
22.d / Name of anesthesia staff or practitioner who performed the pre-sedation (pre-anesthesia assessment).
PC.03.01.01 / 23. / The patient is reevaluated immediately before moderate or deep sedation and before anesthesia induction.
PC.03.01.05 / 24. / Appropriate methods are used to continuously monitor oxygenation, ventilation, and circulation during procedures that may affect the patient’s physiological status.
PC.03.01.07 / 25. / The procedure and/or the administration of moderate or deep sedation or anesthesia for each patient is documented in the medical record.
Post-operative monitoring and documentation of patients includes:
25.a / The patient’s status is assessed immediately after the procedure and/or administration of moderate or deep sedation or anesthesia
25.b / Each patient’s physiological status, mental status, and pain level are monitored
25.c / Patients are discharged from the recovery area and the hospital by a qualified licensed independent practitioner or according to rigorously applied criteria approved by the clinical leaders.
25.d / The use of approved discharge criteria to determine the patient’s readiness for discharge is documented in the medical record.
Standard / Number / Question / Y / N / NA
25.e / The history and physical examination and the results of indicated diagnostic tests are recorded before the operative or other high-risk procedures.
25.f / Post-operative documentation records the name of the licensed independent practitioner responsible for the discharge.
UP.01.01.01
UP.01.02.01
UP.01.03.01 / 26. / Were the (3) parts of the Universal Protocol followed?
26.a / Pre-op verification process (may be checklist)
26.b / Mark surgical site by surgeon or surgical team
26.c / Immediate “Time Out” done and documented
IM.02.01.03 / 27. Operative reports dictated or written immediately after a procedure
record the: (day of surgery) to include the following:
27.a / …name of the licensed independent practitioner and assistants;
27.b / …procedure(s) performed and description of procedure;
27.c / …findings;
27.d / …estimated blood loss;
27.e / …specimens removed;
27.f / …and postoperative diagnosis
28. / An operative or other high risk procedure progress note is entered in the medical record immediately after the procedure, if the full operative or other high risk procedure report cannot be entered into the record immediately after the operation or procedure.
PC.03.01.07 / 29. / Is the pain assessed/reassessed per policy post-procedure?
30. / Is there an anesthesia post-op visit within 24 hours? (not required if local/MAC or moderate sedation performed by attending physician).
31. / Is the anesthesia recovery score present - pre, post or discharge?
32. / Does the physician order match the patient status listed on the face sheet? Admit patient/date/time
Generic Closed Record Review Tool
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Item / MR # / MR # / MR # / MR # / MR # / MR # / MR # / MR # / MR # / MR #Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA
1.a
1.b
1.c
1.d
2.a.
2.b
3.a
3.b
3.c
3.d
3.e
3.f
3.g
3.h
4.a
4.b
4.c
5a.
5b.
5c.
5d.
6
6.a
6.b
7.a
7.b
7.c
7.d
8.a
8.b
ITEM / MR # / MR# / MR # / MR # / MR # / MR # / MR # / MR# / MR # / MR #
Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA
8.c
9.a
9.b
10.a
10.b
10.c
10.d.1
10.d.2
10.d.3
10.d.4
10.d.5
10.d.6
10.d.7
10.d.8
10.d.9
11.a
12.a
12.b
12.c
13.a
13.b
14.a
14.b
14.c
14.d
15.a
15.b
16.a
16.b
16.c
ITEM / MR # / MR# / MR # / MR # / MR # / MR # / MR # / MR# / MR # / MR #
Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA
16.d
16.e
16.f
16.g
16.h
16.i
16.j
16.k
16.l
17.a
17.b
17.c
17.d.1
17.d.2
17.d.3
17.d.4
17.d.5
17.d.6
17.e
17.e.1
17.e.2
17.e.3
17.e.4
17.e.5
17.e.6
18.a
18.b
18.c
18.d
ITEM / MR # / MR# / MR # / MR # / MR # / MR # / MR # / MR# / MR # / MR #
Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA
18.e
18.f
19
19.a
19.b
19.c
19.d
20
20.a
20.b
20.c
20.d
21
21.a
22
22.a
22.b
22.c
22.d
23
24
25
25.a
25.b
25.c
25.d
25.e
25.f
ITEM / MR# / MR# / MR# / MR# / MR# / MR# / MR# / MR# / MR# / MR#
Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA / Y/N/NA
26
26.a
26.b
26.c
27
27.a
27.b
27.c
27.d
27.e
27.f
28
29
30
31
32