AMA & Elopement
This must be assessed and documented before a patient can leave AMA.
What is decision-making capacity?
This process requires the receiver of a critical result to repeat the information back to confirm accuracy.
What is read-back verification?
This documentation tracks all fluids consumed and eliminated by the patient during a defined time period.
What is Intake and Output (I&O) documentation?
This level of disinfection eliminates all microorganisms except high numbers of bacterial spores.
What is High-Level Disinfection (HLD)?
This must match exactly between the consent form, medical record, and scheduled procedure.
What is the procedure name and site
This occurs when a patient chooses to leave the hospital before the provider recommends discharge.
What is Against Medical Advice (AMA)?
This must be documented after receiving a critical test result.
What is provider notification with date and time?
This time of day is recommended for obtaining daily weights to ensure consistency and accuracy.
What is the same time each morning (preferably before breakfast and after voiding)?
This process requires immediate pre-cleaning of equipment at the bedside to prevent bioburden from drying.
What is Point of Use Treatment (POUT)?
This pause immediately before the procedure involves active communication among all team members.
What is the Time-Out?
This event occurs when a patient leaves a secure or monitored area without staff knowledge or authorization.
What is elopement?
This must be verified before communicating a critical result to ensure it matches the correct patient.
What is using two patient identifiers?
This interdisciplinary action should occur if I&O totals are inaccurate or incomplete during a chart audit.
What is education and performance improvement intervention
this transport equipment is kept in the clean utility room
What is the Red box
Failure to follow Universal Protocol can result in this highest-level patient safety event classification.
What is a sentinel event?
This environmental strategy reduces the risk of elopement
What is controlled access or secured unit
This must be documented if the primary provider cannot be reached after receiving a critical value.
What is escalation per chain of command documentation?
This electrolyte imbalance may occur with fluid overload or dehydration and can become a critical test result.
What is sodium imbalance
this occurs immediately or during your shift after proper pre-cleaning
What is transport red box to sterile processing
This must be documented if an emergency procedure is performed without prior consent.
What is emergency exception documentation?
Even if a patient refuses to sign the form when leaving against medical advice, you should still complete this essential step in the chart, detailing the education provided about the benefits of staying for treatment.
What is document the discussion in the medical record?
This timeframe is typically defined by hospital policy for reporting critical values.
What is immediately or within a defined policy timeframe (e.g., 60 minutes)?
This documentation principle applies when fluid imbalance is suspected but not charted clearly.
What is “If it wasn’t documented, it wasn’t done
This must be followed exactly according to manufacturer instructions when performing high-level disinfection.
What are the Instructions for Use (IFU)?
This is only necessary when using the language line or taking a verbal consent over the telephone.
What is a Second Witness