Tracer Patient Audit

AFT2 Accreditation Audit

October 10th, 2014

Tracer Patient Audit

With an audit by the Joint Commission (JC) in the near future, Nightingale Community Hospital (NCH) is performing a tracer patient survey to measure our compliance and identify issues that are in need of remediation. The practice of this type of survey tracks a patient’s care for the duration of their stay starting from the admission process and ending when they are discharged. This system allows us to assess our strengths and weaknesses concerning policy, procedures, and systems in place to provide quality care in conjunction with the standards set forth by the JC.
Summary of Tracer Patient Audit Findings This particular survey was conducted concerning a patient that is a 67 year old female, presenting with fever and drainage approximately 5 weeks after an open hysterectomy. The tracer patient was subsequently admitted for a possible postoperative infection. The tracer patient then endured another surgery to treat the infection that started after the original surgery. The patient also received a central line which is used to administer long-term antibiotics. NCH is arranging to discharge the patient to go home with home health, with the aid of her husband, to help administer her antibiotic therapy after discharge. The audit of this particular patient’s care revealed areas that present an opportunity for correction and improvement. Specifically, the patient did not have a history and physical completed until more than 72 hours after being admitted to NCH. The Joint Commission (n.d.) states that, “The patient receives a medical history and physical examination no more than 30 days prior to, or within 24 hours after registration, or inpatient admission, but prior to surgery or a procedure requiring anesthesia services” (Joint Commission, n.d.,