AFT2 Task 3
Western Governor’s University
A1: Outstanding Gap in Patient Care
The outstanding patient care issue for the organization made evident
... [Show More] by the tracer patient is the history and physical was not completed within twenty-four hours of admission. The history and physical is imperative to collect information on the patient’s past medical history and current health status. Both of which can affect the plan of care of the patient while in the hospital and post-procedure regarding medications and level of care required.
A2: Corrective Action Plan
A policy and procedure will be created to ensure that each patient has a completed history and physical within 24 hours of admission. PC.01.02.03 The hospital assesses and reassess the patient and his or her condition according to defined time frames. (The Joint Commission, 2019)
• The hospital administrator will be responsible for writing the policy and procedure. The policy and procedure will require approval from executive leadership and the medical director. The hospital administrator will delegate the education and implementation of the policy and procedure to the director of nursing.
• The hospital administrator will write the policy and procedure within twenty-one days. Approval signatures from executive leadership and the medical director will be due in thirty days. The director of nursing will educate and train all nurses within forty days. Complete implementation of the policy and procedure will occur in forty-five days.
• The director of nursing will be responsible for training the nursing staff on the new policy and procedure and obtaining signatures from each nurse. The signatures verify that each nurse understands and acknowledge the policy. Weekly chart audits will occur for one month on randomly selected admitted patients to track compliance. Monthly chart audits will occur for the next three months, and quarterly audits will occur from that point on. The director of nursing will be responsible for performing the audits and provide the data to the hospital administrator. Additional training and clarification will occur based on the audit results. Success is measured by 100% compliance to policy. [Show Less]