Temple University Hospital

JCAHO Patient Tracer Survey Tool

Department and Medical Record Number of Date/Time
Patient Chart

Surveyor Team (conductor, recorder, Staff Member(s) Participating

observers)

Compliance Chart Audit and Staff Interviews (Conductor and Recorder)

Yes No Compliance Area Identified Issues for Follow-up

1. Initial Nursing Assessment is
complete:
o all areas are filled in, no
blanks.
o Information is dated and
timed.

2. Abuse assessment is
complete on the Nursing
Assessment form.

3. Spiritual and cultural needs

are assessed and
implemented.

4. Each new patient’s height and

weight are assessed and the
weight is recorded in the MIS
system.

5. All required elements of the

comprehensive assessment of
patient’s initial pain are
documented.

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JCAHO Patient Tracer Survey Tool
6. Pain is reassessed
appropriately:
o pain intensity scale is
documented before and
after intervention
according to policy (at
least once a shift)
o patient pain free during
initial assessment is
reassessed
o appropriate pain
assessment scale is used

7. The Plan of Care for this

patient reflects the patient’s
current condition and has
been revised as needed.

8. The Plan of Care for this

patient reflects the
participation of all appropriate
multidisciplinary
caregivers.

9. The Plan of Care

o states measurable and
meaningful goals
o documents the patient’s
progress toward goals

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10. Progress notes reflect
patient’s progress toward
goals defined in Plan of Care.

11. The “assessment barriers and

preferences” on the pink
patient education form are
filled out appropriately and
completely.
o The patient’s readiness to
learn is assessed prior to
each teaching
intervention.

12. Patient/Family Education

record updated by
multidisciplinary team (i.e.
social work, respiratory care,
nutrition, etc.).

13. Staff can describe process of

patient identification when
collecting
specimens/administering
meds/or performing
procedures AND correctly
identifies the two patient
identifiers used at TUCMC
(name and date of birth)

14. Entries in medical chart are

legible and staff can articulate
what they do if they can’t
read an entry (look for
printed name and/or beeper
number)

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15. How can you find out if a
physician is credentialed to
perform a procedure or
treatment?

16. How do you know what

procedures by virtue of their
level of education residents
are allowed to perform?

17. The H & P has been

appropriately updated (e.g. if
done prior to admission or
procedure, the H & P is
updated by physician)

18. Advance Directive: Staff can

identify whether an advance
directive exists or not; when
it does exist, where it is
located in the chart; what
they do if patient has an
advance directive but patient
or patient’s family does not
provide the advance directive.

19. Staff can articulate the

process for read-back of
critical test results in
response to question: What
would you do if the lab or
radiology called with a critical
test result?

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JCAHO Patient Tracer Survey Tool
20. Patient response to the initial
dose of a new medication is
documented in the chart.
(New Process – not scored)
*Educate Nurses

21. If an adverse drug event has

occurred, it is documented in
the chart.

22. Required Time-Out prior to

Operative and Invasive
Procedures (including
invasive procedures at the
bedside) is documented:
o Site identified
o Individuals involved
o Equipment needs are
available
o Patient identification

23. Restraint orders are limited to

24 hours.

24. Patient is assessed for

alternatives to restraint
intervention.

25. The patient in restraints is

monitored according to the
reason for the intervention
(MS- q 2hrs; Behavioral
Health, q 15).

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26. Describe your competency for
providing care for this patient
(e.g. Nursing; Dietician; PM &
R; Social Work; Case
Management; Pharmacy;
Respiratory)

27. Staff can describe 2

processes that improved care
in their unit/department.

28. Prescribed diagnostic testing

results are on the chart.

29. If an invasive procedure was

done (including invasive
procedures at the bedside)
o a 2-step anesthesia
assessment was
performed
o informed consent
obtained prior to
procedure.

30. If a procedure was done

involving sedation, an airway
assessment was part of the
pre-procedure assessment.

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EOC (Observer)
Yes No Compliance Area Note Issues for Follow-
up
31. Storage is 18” away from the sprinkler heads.

32. Staff observed using appropriate hand-washing

techniques

33. Emergency Crash Cart log up-to-date and complete.

34. Fire Doors, exits and extinguishers are clear and signs are
illuminated.

35. PPE (Personal Protective Equipment) is present in the

designated areas in the department. Isolation techniques
initiated as appropriate and practiced.

36. Area is generally neat and clean.

o Nothing under the sinks.
o Cleaning supplies are locked in patient areas.
o Clean items are separated from soiled items.

37. Oxygen tanks are stored appropriately, no loose tanks in

the department. Maximum amount 12 “E” tanks in any
area.

38. Linen is covered.

39. Storage is at least 6” off the floor and bottom shelf is solid
and clean.

40. Medications (including IV solutions) and syringes are

secured.

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JCAHO Patient Tracer Survey Tool
41. Herbal medications, if ordered, are secured.

42. Patient Food Refrigerator temperature is being monitored

and recorded.

43. Medication Refrigerator temperature is monitored and

recorded.

44. Patient confidentiality of information is protected (charts

not left open; check trash for patient-labeled IV bags and
other confidential information).

45. ID badges on staff are present and visible.

Each question is worth 2 points for total possible score of 90 points.

Score for this tracer (record here and at top of first page):