1. Policy requirements vs. actual systems and processes
For instance, if an order is placed to titrate a drip to keep the Richmond Agitation-Sedation Scale (RASS) at a -2, the survey team will look for the documentation that supports the titration order. Far too often, surveyors find that key elements such as RASS are either not built into the system at all for the nurse to document or nurses are expected to navigate to another screen to document this component. Having the nurse toggle between multiple screens can be a risk to patient safety. There is also an increased probability that the nurse will assess the scale but not remember to document it because the documentation is not located in a place that mimics the required workflow.
2. Variation in electronic health record documentation
Standardization across all areas of your organization ensures that required elements are made clear to staff and practitioners. Wrong-site, wrong-patient, and wrong-procedure surgery continues to be one of the most frequently reported events voluntarily reported to the Joint Commission, with 95 reported events in 2017. High-reliability organizations reduce the variability within their documentation to achieve zero harm.
3. Staff confidence in electronic health record processes
During the survey, your staff will need to feel comfortable sitting with the surveyor to look at the health record retrospectively in some cases. This can be very difficult if staff are not used to looking at a record in this environment. Staff might also be uncomfortable navigating the record if something requested was documented in a different department. The survey process will go smoother if staff are able to navigate the record with ease. Consider nominating someone on staff to be a “super user” who is available to assist staff in navigating the record to locate information requested by the surveyor.
Practice tracers are an excellent way for your staff to gain the confidence they need to locate the following key documents:
- Initial nursing assessment and physical exam
- Pain assessments and reassessments after interventions
- Screenings for suicide risk, including in-depth assessment and appropriate interventions if positive
- Care plans
- Physicians’ orders
- Medication administration record
- Informed consents
- Operative report (immediate note and official report)
- Pre-anesthesia assessment, anesthesia record, and post-anesthesia assessment
- Restraint assessments/monitors
- Discharge plans
Minimizing safety risks and ensuring compliance
Is your electronic health record process built to minimize safety risks and ensure compliance with required documentation elements? The best way to test that theory is to pull records throughout the organization on various topics. For instance, if invasive procedures are performed in numerous areas, then pull one from each area and look for areas in which staff are not documenting according to the policy and for variation in charting.
如果您注意到您有变体，请考虑完成重点风险评估。卫生信息技术（ONC）的国家协调员办公室发表了更安全的指南that assist healthcare organizations in identifying areas within the EHR to improve the overall safety of the health care system.
About Tabitha Garbart, DNP, RN
Fresh from the Joint Commission as a hospital nurse surveyor, Tabitha brings to Compass more than 19 years of experience in the industry and a commitment to helping healthcare organizations connect the dots and understand the “why” behind their work toward a goal of using evidence-based practices to reduce harm and improve quality of care. She previously served as the Chief Quality Officer at Mary Black Health System and has served as a consultant on a continuous survey readiness team assisting Veterans Affairs medical centers to prepare for accreditation visits.阅读有关Tabitha的更多信息。