Patient Care Improvement
Tracer methodology is an evaluation method used by Joint Commission surveyors where they select a patient (resident or client) and use that individual’s record as a roadmap to move through an organization to assess and evaluate the organization’s compliance with selected standards and the organization’s systems of providing care and services. Surveyors retrace the specific care processes that an individual experienced by observing and talking to staff in areas that the individual received care. As surveyors follow the course of a patient’s treatment, they assess the health care organization’s compliance with Joint Commission standards. They conduct this compliance ...view middle of the document...
Action plan below outlines recommended actions for improved compliance.
Patient Tracer Action Plan: Documentation
No. Description Responsible Party Start Date End Date: Add’l Remarks
1 Audit H&P Completion on all new admissions daily basis looking for non-compliance. Documentation Specialist-HIMS Immediate 30 days Notification sent to responsible provider on a daily basis. Follow-up for compliance. Track results for repeat offenders.
2 Audit H&P Compliance on all new admissions for providers identified as repeat offenders during initial 30 day review. Documentation Specialist-HIMS 12-1-12 Ongoing Notification sent to responsible provider on a daily basis. Non-compliance will be tracked and become part of provider’s credentialing file.
3 Periodic random audit for H&P compliance on all new admission (select one day per month). Documentation Specialist-HIMS 12-1-12 Ongoing Notification sent to responsible provider on a daily basis. Non-compliance will be tracked and become part of provider’s credentialing file.
3 Provide mandatory documentation training to all care providers including physicians, nurses and ancillary providers (NP, PA’s etc.) HIMS Director...