A hospital is being surveyed by the Joint Commission and will be experiencing the Joint Commission's tracer methodology. The nursing staff should be prepared to allow the surveyor:
1. Access to one patient's medical record to determine if the organization has complied with Joint Commission standards for patient care.
2. Access to patients to gain the clients' consent to review their medical records.
3. Access to documentation indicating the organization is exploring ways to improve the quality of client care.
4. Access to monitoring results of the organization's effort to improve the quality of client care.
Access to one patient's medical record to determine if the organization has complied with Joint Commission standards for patient care.
Rationale: The Joint Commission currently uses a tracer methodology during accreditation visits. The site surveyor will choose a patient who is hospitalized and use the patient's clinical record as a "road map.". The surveyor reviews the care documented to determine if the organization has complied with standards and systems for providing care. The Joint Commission surveyor would not need consent to review a client's record. The surveyor would adhere to the Health Insurance Portability and Accountability Act Privacy Rule, which indicates that the patient or those health team members involved with the patient's care have a legal right to review the medical record. Access to documentation indicating the organization is exploring ways to improve the quality of client care is part of the surveyor's visit but is not a part of the tracer method. Access to monitoring results of the organization's effort to improve the quality of client care is part of the surveyor's visit but is not a part of the tracer method.
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