An Ambulatory Care Facility’s main purpose is patient care and prevention of illness. Providing the most appropriate care and services in a setting that supports and responds to each patient’s unique needs requires a high level of planning and coordination. This chapter focuses on ambulatory care and the high risk processes of care.
Certain activities are basic to all patient care. For all disciplines that care for patients, these activities include:
• planning and delivering care to each patient;
• monitoring the patient to understand the results of the care; • modifying care when necessary;
• completing the care; and • planning the follow-up.
Many physicians, nurses, pharmacists, rehabilitation therapists, and other types of health care providers may carry out these activities. Each provider has a clear role in patient care. That role is determined by licensure, credentials, certification, law, and regulation. An individual’s particular skills, knowledge, and experience are defined in medical staff privileging or job description documents. Some care may be carried out by the patient, his or her family, or other trained caregivers.
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The Assessment Process
HRC.1 M
All patients cared for by the organization have their health care needs identified through an established assessment process.
Measurable Elements:
M 1. Organization policy and procedure define the information to be obtained for ambulatory patients. M 2. Organization policy and procedure define who
performs the assessment.
M 3. The scope and content of assessments by each discipline are defined in writing.
M 4. Only those individuals permitted by licensure, applicable laws and regulations, or certification perform the assessments.
5. The assessment activities performed in different settings are defined in writing.
HRC.2 M
Assessment findings are documented in the patient’s record and are readily available to those responsible for the patient’s care.
Measurable Elements:
M 1. Appropriate time frames for performing initial assessments and complete assessments are established for all settings and services.
M 2. These assessments are completed within the time frames established by the organization and at a minimum by the third visit for a complete assessment. HRC.3
M
Each patient’s initial assessment includes an evaluation of physical, psychological, social, and economic factors, and each complete assessment includes a physical examination and health history.
Measurable Elements:
M 1. Each patient receives an initial physical assessment. M 2. The complete physical assessment includes a physical
exam and health history.
3. Each patient receives an initial psychological assessment.
4. Each patient receives an initial social and economic assessment.
M 5. The initial assessment results in understanding the care the patient is seeking.
M 6. The initial assessment results in selecting the best setting for the care.
M 7. The initial assessment results in an initial diagnosis.
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M 8. The initial assessment results in understanding anyprevious care.
M 9. The initial assessment results in the identification of the patient’s initial needs.
M 10. The complete assessment results in the identification of the patient’s continuing needs and prevention activities.
HRC.4 M
Pain is assessed in all patients. Measurable Elements:
M 1. All patients are assessed for pain.
M 2. When pain is identified, the patient is referred or a comprehensive assessment is performed appropriate to the patient’s age and measuring pain intensity and quality such as pain character, frequency, location and duration.
M 3. The assessment is recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the organization and the patient needs.
HRC.5 M
Patients are screened for nutritional status and are referred for further assessment and treatment when necessary.
Measurable Elements:
1. Qualified individuals develop criteria to identify patients who require further nutritional assessment. M 2. Patients are screened for nutritional risk as part of the
initial assessment.
3. Patients at risk for nutritional problems according to established criteria receive a nutritional assessment. HRC.6
M
Patients are screened for functional needs and are referred for further assessment and treatment when necessary.
Measurable Elements:
1. Qualified individuals develop criteria to identify patients who require further functional assessment. M 2. Patients are screened for their need for further
functional assessment as part of the initial assessment. 3. Patients in need of a functional assessment according to established criteria are referred for such an assessment.
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HRC.7M
The organization conducts individualized assessments for special populations cared for by the organization.
Measurable Elements:
M 1. The organization identifies those patient populations and special situations for which the initial assessment process is modified, such as pediatric patients, obstetrical patients, geriatric patients, etc.
2. These special patient populations receive individualized assessments.
HRC.8 M
All patients are reassessed at each appointment or at appropriate intervals to determine their response to treatment and to plan for continued treatment or referral.
Measurable Elements:
1. Patients are reassessed to determine their response to treatment.
M 2. Patients are reassessed to plan for continued treatment or discharge.
3. A physician reassesses patients at each appointment. 4. Organization policy defines the circumstances or
types of patients for which a physician’s assessment may be less than each appointment and identifies the reassessment interval for these patients.
5. Patients receiving continued ambulatory care for one year receive a complete physical examination and annually thereafter.
M 6. Reassessments are documented in the patient’s record.
HRC.9 M
The patient’s immediate and continuing medical and nursing needs are identified from the assessment process. Measurable Elements:
1. Patient assessment data and information are analyzed and integrated.
2. Those responsible for the patient’s care participate in the process.
M 3. Patient needs are prioritized based on assessment results.
4. The patient and his or her family participate in the decisions about the priority needs to be met.
HRC.10 M
The medical assessment is documented before anesthesia or surgical treatment.
Measurable Elements:
M 1. Surgical patients have a medical assessment including a physical examination performed before surgery. M 2. The medical assessment of surgical patients is
documented before surgery.
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M 3. Surgical patients have the results of pre-surgicaldiagnostic tests recorded before surgery.
M 4. Surgical patients have a preoperative diagnosis recorded before surgery.
M 5. The anesthesia assessment determines if the patient is an appropriate candidate for the planned anesthesia. HRC.11
M
Qualified individuals conduct the assessments and reassessments.
Measurable Elements:
1. Individuals qualified to conduct patient assessments and reassessments are identified by the organization. M 2. Only those individuals permitted by licensure,
applicable laws and regulations, or certification perform patient assessments.
3. Emergency assessments are conducted by individuals qualified to do so.
4. Nursing assessments are conducted by individuals qualified to do so.
5. Those qualified to conduct patient assessments and reassessments have their responsibilities defined in writing.
Care Delivery
HRC.12M
Care is respectful of the patient’s need for privacy during examinations and treatments.
Measurable Elements:
M 1. A patient’s need for privacy is respected for all examinations, procedures, and treatments.
HRC.13 M
The care provided to each patient is planned and written in the patient’s record.
Measurable Elements:
M 1. The care for each patient is planned.
M 2. The care planned for each patient is noted in the patient’s record.
M 3. The planned care is provided and documented. 4. Any patient care team meetings or other discussions
are noted in the patient’s record.
M 5. The patient’s plan of care is modified as the patient’s needs change.
HRC.14 M
Each care provider has access to the patient care notes recorded by other care providers, consistent with organization policy.
Measurable Elements:
1. There is a method for one care provider to have access to the care notes of other providers.
M 2. The care notes of all providers are timely and are completed at a minimum the day the patient was seen.
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HRC.15M
Those permitted to write patient orders write the order in the patient record in a uniform location.
Measurable Elements:
M 1. Orders are legibly written.
M 2. Only those permitted to write orders do so.
M 3. Orders are found in a uniform location in patient records.
HRC.16 M
The organization follows applicable laws and regulations regarding retention time and has a policy on the retention time of patient records, data, and other information
Measurable Elements:
M 1. The organization follows applicable laws and regulations regarding retention time and has a policy on the retention of patient clinical records and other data and information.
M 2. The retention process provides expected confidentiality and security.
M 3. Records, data, and information are destroyed appropriately.
HRC.17 M
Procedures performed are written into the patient’s record.
Measurable Elements:
M 1. The results of procedures performed are entered into the patient’s record.
Care of High-Risk or Complex Patients
HRC.18 Policies and procedures guide the care of high-riskpatients and the provision of high-risk services. Measurable Elements:
1. Policies and procedures guide: a) the care of emergency patients;
b) the use of resuscitation services throughout the organization;
c) the handling, use, and administration of blood and blood products;
d) the care of patients with a communicable disease and immune-
suppressed patients;
e) the care of patients on dialysis;
f) the use of restraint and the care of patients in restraint;
g) the care of vulnerable elderly patients and of children;
h) the care of patients undergoing moderate and deep sedation.
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2. Staff members have been trained and use the policiesand procedures to guide care.
3. Patients receive care consistent with the policies and procedures.
Sedation, Anesthesia, and Surgery
HRC.19M
Policies and procedures guide the care of patients undergoing moderate and deep sedation.
Measurable Elements:
1. Sedation policies and procedures identify:
a) how planning will occur including the identification of differences between adult and pediatric populations;
b) special consent considerations; c) patient monitoring requirements;
d) special qualifications or skills of staff involved in sedation process;
e) availability and use of specialized equipment. M 2. The qualifications of the physician, dentist, or other
qualified individual responsible for the patient receiving moderate and deep sedation should be competent in:
M a) techniques of various modes of sedation; M b) appropriate monitoring;
M c) response to complications; M d) use of reversal agents; and M e) at least basic life support.
M 3. The responsible qualified individual conducts a pre- sedation assessment of the patient to ensure the planned sedation and level of sedation is appropriate for the patient.
M 4. In addition to the physician or dentist, a qualified individual is responsible for providing uninterrupted monitoring of the patient’s physiological parameters and assistance in supportive or resuscitation measures.
HRC.20 M
A qualified individual conducts a pre-anesthesia assessment.
Measurable Elements:
M 1. A pre-anesthesia assessment is performed for each patient before anesthesia induction.
M 2. A qualified individual performs the assessment. M 3. The anesthesia assessment is recorded before the use
of anesthesia.
M 4. The anesthesia care of each patient is planned based
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on the patient assessment. M 5. The plan is documented.
M 6. Patients are reevaluated immediately before the induction of anesthesia.
HRC.21 The risks, potential complications, and options are discussed with the patient, his or her family, or those who make decisions for the patient.
Measurable Elements:
1. The patient, family, and decision makers are educated on the risks, potential complications, and options of anesthesia.
2. The anesthesiologist or other qualified individual provides the education.
HRC.22 M
The anesthesia used is written in the patient record.
Measurable Elements:
M 1. The anesthesia used and anesthetic technique are entered into the patient’s anesthesia record.
M 2. Each patient’s physiological status during anesthesia administration is continuously monitored and written in the patient’s record.
HRC.23 M
Each patient’s post-anesthesia status is monitored and documented, and a qualified individual discharges the patient from the recovery area using established criteria.
Measurable Elements:
M 1. Patients are monitored appropriate to their condition during the post-anesthesia recovery period.
M 2. Monitoring findings are entered into the patient’s record.
M 3. Established criteria are used to make discharge decisions.
M 4. A qualified individual applies the criteria and discharges the patient.
5. Recovery beginning and discharge times are recorded. HRC.24
M
Each patient’s surgical care is planned and documented based on the results of the assessment.
Measurable Elements:
M 1. The surgical care of each patient is planned.
M 2. The planning process considers all available assessment information.
M 3. The planned surgical care is documented.
M 4. A preoperative diagnosis is documented prior to the procedure.
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HRC.25 M
The risks, benefits, potential complications, and alternatives are discussed with the patient and his or her family or those who make decisions for the patient.
Measurable Elements:
M 1. The patient, family, and decision makers are educated on the risks, benefits, potential complications, and alternatives related to the planned surgical procedure. 2. The education includes the need for, risk of, and
alternatives to blood and blood product use.
M 3. The patient’s surgeon or other qualified individual provides the education.
HRC.26 M
The surgery performed is written in the patient record.
Measurable Elements:
M 1. A post-operative diagnosis is documented.
M 2. A description of the surgical procedure, findings, and any surgical specimens is documented.
M 3. The names of the surgeon and surgical assistants are documented.
M 4. The surgical report is available before the patient completes the recovery phase so that all care givers can provide appropriate post-surgical care to the patient.
Medication Use
HRC.27 M
Medication use in the organization complies with applicable laws and regulations.
Measurable Elements:
1. Medication use is organized throughout the organization so that patient medication needs are met. M 2. The pharmacy or pharmaceutical service and medication use comply with applicable laws and regulations.
HRC.28 M
An appropriate selection of medications is stocked or readily available.
Measurable Elements:
M 1. Medications available for prescribing and ordering are appropriate to the organization’s mission, patient needs, and services provided.
M 2. There is a list of medications stocked in the organization or readily available from outside sources.
3. There is a method for oversight of the medication list. M 4. There is a method for oversight of medication use
within the organization.
M 5. Medications are protected from loss or theft.
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M 6. There is a process to obtain required medications not stocked or normally available to the organization. 7. Staff members understand the process.
HRC.29 M
The organization identifies those qualified individuals permitted to prescribe or order medications and those permitted to administer medications.
Measurable Elements:
M 1. Only those permitted by the organization and by relevant licensure, laws, and regulations prescribe or order medications.
2. Individuals permitted to prescribe and order medications are known to the pharmaceutical service or others who dispense medications.
M 3. Only those permitted by the organization and by relevant licensure, certification, laws, or regulations administer medications.
HRC.30 M
Medications are stored, prepared, and dispensed in a safe, clean, and secure environment.
Measurable Elements:
M 1. Medications are labeled properly.
M 2. Medications are stored under conditions suitable for product stability in a secure environment.
3. Medications are prepared and dispensed in clean and safe areas.
M 4. Medications preparation and dispensing adhere to law, regulation, and professional standards of practice.
HRC.31 M
An appropriately licensed pharmacist, technician, or other trained professional supervises the storage, preparation, and dispensing of medications.
Measurable Elements:
M 1. An appropriate licensed, certified and qualified individual supervises all activities.
M 2. Medications are accurately dispensed.
M 3. Controlled substances are accurately accounted for. HRC.32
M
The organization has a medication recall system.
Measurable Elements:
M 1. There is a medication recall system in place.
M 2. Policies and procedures address the destruction and disposal of medications known to be expired or outdated.
3. Policies and procedures are implemented.
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HRC.33 M
A system is used to dispense medications in the right dose to the right patient at the right time.
Measurable Elements:
1. There is a uniform medication dispensing and distribution system in the organization.
2. Medications are dispensed in a form requiring minimal manipulation.
M 3. The system supports accurate dispensing. M 4. The system supports timely dispensing. HRC.34
M
Patients are identified before medications are administered.
Measurable Elements:
M 1. There is a system in place to ensure the identification of patients.
M 2. Patients are identified before medications are administered.
M 3. Medications are verified with the prescription or order.
M 4. The dosage amounts of the medication are verified with the prescription or order.
M 5. The routes of administration are verified with the prescription or order.
6. Medications are administered on a timely basis. M 7. Medications are administered as prescribed.
HRC.35 Medication effects on patients are monitored including adverse effects.
Measurable Elements:
1. Medication effects on patients are monitored, including adverse effects.
2. The monitoring process is collaborative. HRC.36
M
Medications prescribed and administered are written in the patient’s record.
Measurable Elements:
M 1. Medications prescribed or ordered are recorded for each patient.
2. Medication administration is recorded for each dose. M 3. Medication information is kept within the patient’s
record. HRC.37
M
Adverse medication effects are noted in the patient’s record.
Measurable Elements:
1. Monitoring includes observing and documenting adverse medication effects.
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2. The organization has identified those adverse effectsthat must be reported to the organization. M 3. Adverse effects are reported as required.
Infection Control
HRC.38 M
The organization establishes the focus of the infection prevention and reduction program consistent with laws, regulations, and acceptable practices..
Measurable Elements:
M 1. The organization has established the focus of the program to prevent or reduce the incidence of infections.
2. Intravascular invasive devices are included as appropriate to the organization.
3. Urinary infections are included as appropriate to the organzation.
4. Respiratory infections are inlcuded as appropriate to the organization.
5. Surgical wounds are included as appropriate to the organization.
6. Communicable and epidemiologically significant diseases and organisms are inlcuded as appropriate to the organization.
HRC.39 M
The organization identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk.
Measurable Elements:
M 1. Equipment cleaning and sterilization are included as