Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and...
Transcript of Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and...
![Page 1: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/1.jpg)
StorkTJC (The Joint Commission) Readiness Scavenger Hunt
![Page 2: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/2.jpg)
Table of Contents
• Demographics• Race and ethnicity• Preferred language
• Education• Learning needs• Patient education
• Nursing Assessments• Initial/Ongoing• Nutritional screen• Fall risk• Abuse/Neglect• Suicide Risk• Pain Assessment/Reassessment• Advance Directives
• Physician Documentation• History and physical• Consult notes • Authentication of orders
• Medication • Medication reconciliation on admission, discharge or transfer• Clarity of orders
![Page 3: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/3.jpg)
• Procedural Documentation• Informed consent• Pre-anesthesia assessment• Immediate pre-induction assessment• Pre-procedure checklist• Timeout• Immediate post-op note• Post-anesthesia assessment
• Ancillary Documentation• Discharge planning• Respiratory therapy• PT/OT• Wound Consult• Social Work• Dietary
• Restraint Documentation• Orders• Monitoring• Inclusion in plan of care
Table of Contents (cont’d)
![Page 4: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/4.jpg)
Demographics: Race and EthnicityGrease board > Patient Chart > Patient Name > Contact Information tab/Clinical Information tab
![Page 5: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/5.jpg)
Demographics: Preferred Language
Patient Chart > Patient Header > Language: field
![Page 6: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/6.jpg)
Education: Learning Needs and Patient Education
Patient chart > Education Activity > Education tabPatient Chart > Education Activity >
Assessment Tab
![Page 7: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/7.jpg)
Nursing Assessments: Nutritional Screening, Fall Risk, Abuse/Neglect, Pain, Advance Directives
Patient Chart > Navigators Activity > Advance Directives, Nutrition, Psychosocial (Abuse/Neglect), Fall Risk
![Page 8: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/8.jpg)
Nursing Assessments: Initial/Ongoing, Suicide Risk
Patient Chart, Flowsheet Activity > Assessment or All Doc tab/Suicide Risk Assessment (may need to be wrenched in)
![Page 9: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/9.jpg)
Nursing Assessments: Pain Assessment/Reassessment
Patient Chart, Flowsheet Activity > All Doc tab > Pain
![Page 10: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/10.jpg)
Provider Documentation: H&P, Consult Notes
Patient Chart > Notes Activity > Sort by Type (H&P or consult)
![Page 11: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/11.jpg)
Provider Documentation: Authentication of OrdersPatient Chart > Orders Activity > Order History
![Page 12: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/12.jpg)
Medication: Med Rec on Admission/Transfer/Discharge
Patient Chart > Navigators > Triage/Transfer/Discharge tab > Med Rec Status
![Page 13: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/13.jpg)
Medication: Clarity of Orders
Patient Chart > MAR Activity > Click in the medication box and it will show all detailsAlso can use the Show All Details Filter and the details of all MAR orders will expand
![Page 14: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/14.jpg)
Procedural Documentation: Informed Consent, Pre-Anesthesia Assessment, Immediate Pre-Induction Assessment, Pre-Procedure Checklist, Timeout, Post-Anesthesia Assessment
Patient Chart > Chart Review > Procedures tab > Click on procedure note to open detail of the procedure
![Page 15: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/15.jpg)
Procedural Documentation: Immediate Post-Op Note
Patient Chart > Chart Review > Procedures tab > Click on procedure note to open detail
![Page 16: Stork TJC (The Joint Commission) Readiness …...Table of Contents • Demographics • Race and ethnicity • Preferred language • Education • Learning needs • Patient education](https://reader035.fdocuments.in/reader035/viewer/2022062604/5fbb3233894c210d6d021ec9/html5/thumbnails/16.jpg)
Ancillary Documentation
FYI: Clicking the “Type” header will sort notes by type and make finding notes by ancillary departments faster
Patient Chart > Chart Review Activity > Notes tab > sort by type to find ancillary department name