Template

JHHS SMH Chart Review Tracer

by Nicole Tietz, from the Community

20+

Use this Joint Commission mock tracer checklist from Sibley Memorial Hospital to review inpatient records for compliance. The tool guides chart reviewers through H&P requirements, daily physician progress notes, medication reconciliation, allergy documentation, pre-op checklists, time-outs, discharge summaries, restraints, nursing assessments, fall risk protocols, patient education, pain assessments, and advance directives. It also covers anesthesia evaluations and operative notes, helping teams verify documentation timeframes, signatures, and interdisciplinary plans of care to prepare for surveys and improve patient safety.

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About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
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.
by Anne Steele, from the Community
Downloads: 30+
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Template
JHHS SMH Staff Interview Tracer
Prepare staff for Joint Commission mock surveys at Sibley Memorial Hospital with this structured interview tracer. It covers environment of care, emergency management, information management, life safety, patient safety and national patient safety goals, performance improvement, provision of care, infection prevention, medication management, and patient rights. Use it to verify reporting processes, hand hygiene, SBAR handoffs, specimen labeling, equipment cleaning, waste disposal, and response protocols such as RACE, PASS, and Code Pink. Ideal for training, auditing, and continuous quality improvement.
by Robert Carter, from the Community
Downloads: 20+
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Template
Inpatient Unit Tracer
This comprehensive healthcare documentation guide outlines essential compliance requirements and protocols for medical facilities. It covers critical areas including pre-operative documentation, anesthesia assessments, surgical procedures, nursing care, and safety protocols. The guide details specific requirements for patient documentation, including H&P updates, informed consent, time-out procedures, and post-operative notes. It also addresses important nursing documentation requirements such as care plans, medication management, fall protocols, and advance directives. Additionally, the guide includes vital safety and compliance measures for equipment handling, infection control, medication storage, and emergency preparedness. This resource serves as a complete reference for healthcare providers to maintain regulatory compliance and ensure high-quality patient care documentation.
by Tameria Joy, from the Community
Downloads: 50+
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Template
JHHS SMH Procedure Area Tracer
This Joint Commission mock survey checklist helps hospitals audit procedure areas for compliance and patient safety. It covers informed consent and patient education, history and physical timing, anesthesia and sedation assessment, National Patient Safety Goals including patient identification, hand hygiene, hand-offs and medication labeling, pre-procedure verification, site marking, surgical time-out, immediate post-op notes, and proper documentation to support readiness for accreditation.
by Robert Carter, from the Community
Downloads: 10+
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JHHS SMH Chart Review Tracer

With SafetyCulture you can

Digitize team workflows

Reduce manual errors

Create and share inspection reports

About author

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JHH Adult Inpatient Tracer Tool

JHHS SMH Staff Interview Tracer

Inpatient Unit Tracer

JHHS SMH Procedure Area Tracer

You might also like

JHH Adult Inpatient Tracer Tool

JHHS SMH Staff Interview Tracer

Inpatient Unit Tracer

JHHS SMH Procedure Area Tracer