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Informed Consent Form Sample

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Informed Consent Form Sample Powered By Docstoc
					SAMPLE TRACER WORKSHEET

This worksheet follows the course of treatment for hypothetical patient Mr. J. D. as given in
chapter 9. The worksheet is divided into sections corresponding to the departments in
which Mr. J. D. was given care, treatment and services during this episode of care.

This worksheet (and its corresponding document, "Sample Tracer Document") were adapted
from our Hospital Data Elements Worksheet_1 and Hospital Data Elements_2 using the time-
honored cut-and-paste method. Practitioners are encouraged to use our Worksheets and
Documents to make their own tracer worksheets and documents that are tailor-made for
their organizations.

To begin using the form, click on the tab below marked "Sample Tracer Worksheet"
Record No. ______________________________                Service Date _____________________________
Admission Date __________________________                Review Date _____________________________
Discharge Date __________________________                Reviewer's Initials _________________________
Responsible Physician ____________________

           SAMPLE TRACER WORKSHEET
                       HOSPITAL UNIT
ADMISSION VIA EMERGENCY DEPARTMENT                                                                 Yes No N/A
1. Patient's name, sex, address, date of birth and authorized representative, if any          1
2. Reason(s) for admission for care, treatment, or services                                   2
3. Evidence of appropriate informed consent includes nature of the proposed care,             3
    treatment, medications, interventions or procedures, potential benefits, risks or side
    effects, including potential problems related to recuperation, ….
4. Evidence of informed consent when required by organization policy                          4
5. Evidence of known advance directives                                                       5
6. The existence or lack of an advanced directive does not determine an individual's          6
    access to care, treatment, and services. Documentation indicates whether or not
    the patient has signed an advance directive.
7. Legal status of patients receiving behavioral health care services                          7
8. Emergency care, treatment, and services provided before arrival, if any                     8
9. Documentation of findings and assessments                                                   8
10. The medical record of patients who have received emergency care, treatment                10
    and services contains the following information:
      -Time and means of arrival
      -Whether the patient left against medical advice
      -The conclusions at termination of treatment, including final disposition, condition,
    and instructions for follow-up care, treatment, and services
      -Notation that a copy of the record is available to the practitioner or medical
    organization providing follow-up care, treatment, and services

ASSESSMENT OF PATIENT
11. Assessment includes physical, psychosocial, social nutrition and hydration status,        11
    functional status, (for patients receiving end of life care, this includes social,
    spiritual, and cultural variables)
12. Medical history and physical within 24 hours of admission                                 12
13. Comprehensive pain assessment appropriate to patient's condition and the scope of         13
     care, treatment, and services provided
14. Conclusions or impressions drawn from the medical history and physical exam               14
15. Initial nursing assessment within 24 hours of inpatient admission                         15
16. The diagnosis, diagnostic impression or conditions                                        16
17. The medical record contains sufficient information to identify the patient, support the   17
   diagnosis/condition, justify the care, treatment, and service; document the course and
   results of care, treatment, and service; and promote continuity of care among providers
18. A nutritional screening, when warranted by the patient's needs of conditions, is          18
   completed within 24 hours of inpatient admission
19. Allergies to food and medicine                                                            19
20. A functional status screening, when warranted by the patient's needs of conditions,       20
   is completed within 24 hours of inpatient admission
Record No. ______________________________                Review Date _____________________________
                         SAMPLE TRACER WORKSHEET (Page 2)                                   Yes No N/A
21. If applicable, separate specialized assessment and reassessment information          21
   is identified for the various populations served
22. Need to plan for discharge or transfer is determined                                 22
23. Each patient is reassessed as needed                                                 23
24. Have staff members integrated information from various assessments of the patient    24
   to develop a plan for care, treatment, and services?
25. Were the care, treatment, and services planned appropriate to the patient's needs?   25

RADIOLOGY UNIT
26. Is the patient ID form with name, record No., address and demographics present?           26
27. Does each page contain patient identification?                                            27
28. The medical record contains sufficient information to identify the patient, support the   28
   diagnosis/condition, justify the care, treatment, and service; document the course and
   results of care, treatment, and service; and promote continuity of care among providers
29. Every medical record entry is dated, author identified, and when necessary                29
   according to policy, authenticated
30. Goals of treatment & treatment plans are documented                                       30
31. Consultation reports, as applicable                                                       31
32. All diagnostic and therapeutic procedures, tests, and results are documented              32

OPERATIVE AND INVASIVE PROCEDURES
33. Is the patient ID form with name, record No., address and demographics present?           33
34. Does each page contain patient identification?                                            34
35. Was the patient correctly identified prior to the procedure?                              35
36. A provisional diagnosis is recorded before the operative procedure by the                 36
   LIP responsible for the patient
37. A complete informed consent process includes a discussion of the following elements:      37
   potential benefits, risks, or side effects, including potential problems related to
   recuperation
38. Before the operative and other procedures or the administration of moderate or deep       38
   sedation or anesthesia, a presedation or preanesthesia assessment is conducted
   effects, including potential problems related to recuperation, ….
39. Before sedating or anesthetizing a patient, a LIP with appropriate clinical privileges    39
   plans or concurs with the planned anesthesia
40. Patient is reevaluated immediately before moderate or deep sedation and before            40
   anesthesia induction
41. Appropriate methods are used to continuously monitor oxygenation, ventilation, and        41
   circulation during procedures that may affect the patient's physiological status
42. Post-operative monitoring (PC.13.40) and documentation (IM.6.30) of pat's includes:       42
43. Physiological Status                                                                      43
44. Mental Status                                                                             44
45. Medications (including intravenous fluids)                                                45
46. Blood and blood components administered, if applicable                                    46
47. Vital signs and level of consciousness                                                    47
48. Pain level                                                                                48
49. Any unusual events or complications, (including blood transfusion reactions) and          49
   the management of those events
Record No. ______________________________                Review Date _____________________________
                        SAMPLE TRACER WORKSHEET (Page 3)                                    Yes No N/A
50. Patients are discharged from the recovery area and the organization by a qualified   50
   licensed independent practitioner according to rigorously applied criteria approved
   by the clinical leaders
51. The use of approved discharge criteria to determine the patient's readiness for      51
   discharge is documented in the medical record
52. The completed operative report is authenticated by the surgeon and made available    52
   in the medical record as soon as possible after the procedure

   OPERATIVE REPORTS DICTATED OR WRITTEN IMMEDIATELY AFTER A
   PROCEDURE RECORD THE:
53. Findings                                                                                   53
54. Procedures performed and description of the procedure                                      54
55. Specimen(s) removed                                                                        55
56. Post-operative diagnosis                                                                   56
57. Name of primary surgeon and assistants                                                     57
58. Estimated blood loss, as indicated                                                         58
59. An operative progress note is entered immediately after the procedure                      59
60. Postoperative documentation records the patient's discharge from the postsedation          60
   or postanesthesia care area by the responsible LIP or according to discharge criteria
61. Postoperative documentation records the name of the LIP responsible for discharge          61

ORTHOPEDIC UNIT
62. Is the patient ID form with name, record No., address and demographics present?            62
63. Does each page contain patient identification?                                             63
64. The medical record contains sufficient information to identify the patient, support the    64
   diagnosis/condition, justify the care, treatment, and service; document the course and
   results of care, treatment, and service; and promote continuity of care among providers
65. Every medical record entry is dated, author identified, and when necessary                 65
   according to policy, authenticated
66. Goals of treatment & treatment plans are documented                                        66
67. Consultation reports, as applicable                                                        67
68. All diagnostic and therapeutic procedures, tests, and results are documented               68

EDUCATION
69. Is the patient ID form with name, record No., address and demographics present?            69
70. Does each page contain patient identification?                                             70
71. Assessment of learning needs addresses cultural and religious beliefs, emotional           71
   barriers, desire and motivation to learn, physical or cognitive limitations, and barriers
   to communication as appropriate
72. Is the educational process coordinated among the disciplines providing care,               72
   treatment, and services?
       As appropriate to the patient's condition and assessed needs and the
       organization's scope of services, the patient is educated about the following:
73. The plan for care, treatment, and services                                                 73
74. Basic health practices and safety                                                          74
75. The safe and effective use of medications                                                  75
76. Nutrition interventions, modified diets, or oral health                                    76
Record No. ______________________________                  Review Date _____________________________
                        SAMPLE TRACER WORKSHEET (Page 4)                                      Yes No N/A
77. Safe and effective use of medical equipment or supplies provided by the organization   77
78. Habilitation or rehabilitation techniques to help them reach maximum independence      78
79. Understanding pain, the risk for pain, the importance of effective pain management,    79
   the pain assessment process, and the methods for pain management
80. When indicated and before discharge , the organization arranges for or helps the       80
   family arrange for services needed to meet the patient's needs after discharge
81. When appropriate , specific academic educational needs of children and                 81
   youth are addressed

DOCUMENTATION OF CARE/TRANSITIONAL CARE UNIT
82. Is the patient ID form with name, record No., address and demographics present?           82
83. Does each page contain patient identification?                                            83
84 Every medical record entry is dated, author identified, and when necessary                 84
   according to policy, authenticated
85. At a minimum the following are authenticated either by written signature,                 85
   electronic signature, or computer key or rubber stamp
86. - history and physical examination                                                        86
87. - consultations                                                                           87
88. - operative report                                                                        88
89. - discharge summaries                                                                     89
90. Each verbal order is dated and identifies the names of the individuals who gave and       90
   and received it, and the record indicates who implemented it
91. When required by state and federal law and regulation, verbal orders are                  91
   authenticated within defined time frame
92. Goals of treatment & treatment plans are documented                                       92
93. Evaluation of the patient is based on the patient's care goals and the patient's plan     93
    for care, treatment and services
94. Relevant observations                                                                     94
95. Progress notes made by authorized individuals                                             95
96. Consultation reports, as applicable                                                       96
97. Monitoring of a medication's effect on the patient includes: 1) gathering the patient's   97
   own perceptions about side effects, and when appropriate, perceived efficacy; and
   2) referring to information from the patient's medical record, relevant laboratory
   results, clinical response, and medication profile
98. Every medication ordered or prescribed                                                     98
99. All diagnostic and therapeutic procedures, tests, and results                              99
100. The organization has a policy and procedures on the timely entry of all significant      100
   information into the patient's medical record
   or treatments
101. The organization defines a complete record and the time frame within which the           101
   record must be completed after discharge, not to exceed 30 days after discharge
102. The organization measures medical record delinquency at regular intervals, no less       102
   frequently than every three months
103. The organization communicates appropriate information to any organization or             103
     provider to which the patient is transferred or discharged
Record No. ______________________________               Review Date _____________________________
                       SAMPLE TRACER WORKSHEET (Page 4)                                        Yes No N/A
104. The information shared includes the following, as appropriate to the care, treatment, 104
    and services provided:
      -Reason for transfer or discharge
      -Patient's physical and psychosocial status
      -A summary of care, treatment, and services provided and progress toward goals
      -Community resources or referrals provided to the patient
                      SKILLED NURSING UNIT
CARE PLANNING
105. Is the patient ID form with name, record No., address and demographics present?         105
106. Does each page contain patient identification?                                          106
107. An interim care plan is developed after admission                                       107
108. ID care plan developed no later than 1 wk after initial assessments (which              108
   occur within 14 days)
109. Care planning is individualized to address residents' needs and problems                109
110. Individual care & treatment goals are identified in the care-planning process           110
111. Goals are reasonable                                                                    111
112. Goals are measurable                                                                    112
113. Care is planned in a coordinated and collaborative approach TX.5 The                    113
   interdisciplinary plan includes a plan for nutrition care (Score at TX.1.3)
114. IDT members participate in planning care                                                114
115. Services are identified and planned to meet goals                                       115
116. IDT members responsible for providing care are identified in care plans                 116
117. Care plans indicate how frequently services will be provided                            117
118. Evidence of resident/family participation in developing and reviewing the care plan     118
119. Care plans and goals are documente                                                      119
120. Appropriate interventions identified in the care plan are provided (NON-REHAB)          120
121. Resident's response to care is evaluated                                                121
122. The care plan is evaluated at least every 90 days and when there is significant         122
   change in condition
123. Care plans are revised to reflect current needs, and significant change in condition    123
124. Nutrition and hydration status is monitored and documented                              124
125. Quarterly documentation of the provision and of response to the activities program      125
126. Quarterly documentation of the provision and response to the nutrition care             126
127. Quarterly documentation of the provision of and response to nursing care                127
128. Quarterly documentation of the provision of and response to social service interventions128
129. Documentation of significant changes in resident's care/treatment                       129
130. Effects of medications are documented                                                   130
MEDICAL ASSESSMENT/SERVICES
131. Medical assessment/H&P/completed in 72 hours                                            131
132. Initial medical assessment and statement of conclusions or impressions drawn from       132
   medical history and physical examination
133. Diagnosis or diagnostic impression                                                      133
134. Reason(s) for admission or treatment                                                    134
135. Medical treatment and care/Medical progress notes                                       135
136. MD visits once during 30 days after admission                                           136
137. MD visits every 30 days for first 90 days after admission                               137
138. MD visits every 60 days thereafter                                                      138

				
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Description: Informed Consent Form Sample document sample