One patient identified as our tracer, 67 year old female who presented to the hospital with a fever and drainage five weeks after hysterectomy. She was admitted with suspicion of post-operative infection. She underwent second surgery to treat the abscess by draining it and put a long term antibiotic treatment via central line. The patient was a postoperative from planned laparoscopic hysterectomy.
During the tracer patient care showed some areas that need improvement after reviewing the compliance material. According to The Joint Commission mandates, “PC.01.02.03 is a provision of care which requires assessment and reassessment of the patient condition according to hospital defined time frames. The history and physical should be completed within 24 hours of admission but in this case the history and physical was completed more than 72 hours of admission. Although the assessment was performed later this is an indication of timeliness and not lack of skills. The history and physical needed to be done before any procedure is done. The history and physica...
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...ical. They will then sign an MOU stating they understand the importance and put in everyone’s file.
3. Print a copy of the policy and hang it in the nurse’s room.
4. The tracer should be done annually to make sure it is done accurately.
5. The nurse supervisor should review patient chart to see which individual is not compliant and go over it with the individual and have it signed and dated they understand the importance of history and physical.
6. Team lead should review chart within 24 hours of admission to make sure it’s done
7. Continuous education should be provided
8. If an individual continues making the same mistake then a warning will be issued and during the pay rise they may not get it.
9. Chart to be reviewed before the procedure and if requirements are not met, patient should be held in the OR until the history and physical are done 100 compliance.
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