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2004 Survey Series: Tracer Methodology Mock Survey Training

Staff Development Weekly: Insight on Evidence-Based Practice in Education, May 6, 2004

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Q: While reviewing a geriatric patient's chart, the surveyor notes that the patient went to radiology for a procedure. What can you expect the surveyor to ask?

A: Expect the surveyor to ask about your preparation for the procedure and the information that the patient care unit provided to the radiology department. The surveyor may even go one step further, asking nursing staff to explain how you educate staff and physicians about moderate sedation, who administers moderate sedation, who monitors the patient, and how you determine when a patient is ready for discharge. Expect the surveyor to request the credential file of the physician who performed a certain procedure on a patient and the personnel file of the nurse who cared for the patient. The personnel file should include evidence of education and competency assessment, as outlined in your hospital policies. The credential file should show that the physician is permitted to administer moderate sedation, as well as whether the physician's competencies were reassessed upon his or her reappointment.

Editor's note: The above case is from the online course "2004 Survey Series: Tracer Methodology Mock Survey Training." For more information on this and other accreditation courses, go to www.hcprofessor.com and click on JCAHO Survey Preparation/Patient Safety.

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