Medical Records & Documentation
How do you protect patient privacy & confidentiality?
We access patient records only on a need-to-know basis, log off of computers when not in use, and do not discuss patient information in public areas. Keep patient information out of public view. Follow HIPAA regulations.
What is Code Red?
Fire
Color Code for extinguishers
Where is the closest pull station
What do you do if a surveyor asks you a question that you do not know the answer to?
Tell them you don't know the answer, but you will find out and get the answer to them. Only give them the information they ask for.
How is a fall risk identified, and what is done to prevent a fall?
Patients are assessed for fall risk upon admission and regularly throughout their stay. High-risk patients are given colored wristband and non-slip socks, and staff implement specific interventions like bed/chair alarms, magnet for doorway, and frequent rounding.
Where do you locate policies?
PolicyStat
Be familiar with the policies specific to your area.
What should you do if you find a box or other item blocking a hallway or exit?
We immediately move the obstruction to ensure clear access. We report ongoing issues or safety hazards to our supervisor or facilities management
What should the surveyor NOT find during walking rounds?
Outdated items, no food/drinks in patient care areas, no cardboard, no heaters/unapproved extensions, no doors propped open, restricted areas not secured, stained ceiling tiles, cluttered hallways, exits blocked...
What is to be stored in patient ONLY refrigerator?
Unexpired snacks & drinks for patients
Temperature logs for refrigerators/freezers
If it's not documented, then___________?
All care is documented accurately and in a timely manner in the electronic health record (EHR). We include details on the patient's condition, our interventions, and the patient's response.
Where do we keep O2 Cylinders?
Properly stored in racks in their appropriate rooms. DO NOT: carry them, leave unattended in public areas
What do your Success Boards represent?
Department: PI projects, goals, staff recognition...
What are your emergency procedures for a fire or other life-threatening event?
We follow the RACE and PASS protocols. RACE stands for Rescue, Alarm, Confine, and Extinguish/Evacuate. PASS describes how to use a fire extinguisher: Pull the pin, Aim the nozzle, Squeeze the handle, and Sweep from side to side. All staff participate in regular drills to ensure we know the procedures.
How do patients obtain lab results?
HIM - complete medical release or patient portal.
What do you do if you find a faulty piece of equipment?
Lock Out/Tag Out (policy)
Notify administration.
What are the hospital's protocols for hand hygiene?
All staff must wash their hands or use an alcohol-based hand sanitizer before and after every patient encounter, after touching any potentially contaminated surface, and after removing gloves.
What are a patient's rights in this hospital?
We inform patients of their rights upon admission, which include the right to make decisions about their care, receive information about their treatment in a language they can understand, and file a grievance without fear of reprisal.
Where are the Safety Data Sheets (SDS) located for the chemicals in this department?
The SDS information is accessible through our computer system.
What do we report in RLS?
Falls, complaints/compliment, unexpected outcomes, AMA, needle stick, medication error, injuries, professional misconduct; anything out of the ordinary or not the standard operating procedure.
Where do you find information on isolation precautions for a patient?
Isolation precautions are clearly posted on the patient's door. Additional information can be found in our hospital's infection control policies and procedures manual.