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StorkTJC (The Joint Commission) Readiness Scavenger Hunt
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
• 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)
Demographics: Race and EthnicityGrease board > Patient Chart > Patient Name > Contact Information tab/Clinical Information tab
Demographics: Preferred Language
Patient Chart > Patient Header > Language: field
Education: Learning Needs and Patient Education
Patient chart > Education Activity > Education tabPatient Chart > Education Activity >
Assessment Tab
Nursing Assessments: Nutritional Screening, Fall Risk, Abuse/Neglect, Pain, Advance Directives
Patient Chart > Navigators Activity > Advance Directives, Nutrition, Psychosocial (Abuse/Neglect), Fall Risk
Nursing Assessments: Initial/Ongoing, Suicide Risk
Patient Chart, Flowsheet Activity > Assessment or All Doc tab/Suicide Risk Assessment (may need to be wrenched in)
Nursing Assessments: Pain Assessment/Reassessment
Patient Chart, Flowsheet Activity > All Doc tab > Pain
Provider Documentation: H&P, Consult Notes
Patient Chart > Notes Activity > Sort by Type (H&P or consult)
Provider Documentation: Authentication of OrdersPatient Chart > Orders Activity > Order History
Medication: Med Rec on Admission/Transfer/Discharge
Patient Chart > Navigators > Triage/Transfer/Discharge tab > Med Rec Status
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
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
Procedural Documentation: Immediate Post-Op Note
Patient Chart > Chart Review > Procedures tab > Click on procedure note to open detail
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