JHH Adult Inpatient Tracer Tool

This JHH Adult Inpatient Tracer Tool supports hospital teams in auditing end-to-end inpatient care and documentation. Sections cover nursing and provider documentation, pre-op checks, anesthesia consent and assessments, surgical time-outs, post-anesthesia evaluations, H&P requirements and updates, procedural informed consent, immediate and detailed post-op notes, and restraint use with orders, assessments, and education. It also guides nursing plans of care, admission screening, medication reconciliation, critical action value notifications, fall protocols, patient education, pain assessment and management, advance directives, medication ordering and administration safety (including chemotherapy), VAD and central line checklists, infection prevention practices, equipment management, emergency preparedness, patient environment standards, alarm response, and EVC cleaning audits.