Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
Compliance tips for:
Examples of ACHC Surveyor findings: ■ The hospital’s policy “Consents for Medical Procedures” lacked required elements. ■ The process for obtaining consent in/after an emergency situation was not completed per hospital policy. ■ Surgical consents were not written in a language the patient understood. ■ Surgical consent for a patient whose primary language was Spanish lacked evidence that an interpreter was provided to assist in understanding the consent. Compliance tips for:
The standard is designed to support the integrity and cleanliness of supplies and to prevent diversion and other forms of loss.
Nerd Newbies (understand the requirement)
■ Audit storage for appropriate segregation of items. ■ Audit storage spaces for the minimum six-inch floor clearance for non- sterile supplies and food items and eight-inch floor clearance for sterile supplies and a solid surface for bottom shelves. ■ Audit for locked doors/storage cabinets where medications, sharps, or other items subject to diversion risk are kept. ■ Add expectations for storage in various locations to the environmental rounding audit tool. ■ Review risk assessments to ensure that they result in a recommendation which is followed.
Nerd Apprentices (audit for excellence)
Informed consent means the patient or their representative is provided the information needed to agree to a procedure or treatment. This means the hospital identifies procedures/treatments that require consent in a policy that also describes the process. Documentation to be signed by the patient must use language accessible to a non-medical professional. ■ Audit medical records of patients who underwent a procedure requiring consent for a signed form. Check for the use of simple terms to describe the treatment/procedure. ■ Audit consent forms for all required signatures. ■ Audit surgical consents for completion prior to the procedure. ■ Compare consent forms to policy to ensure alignment. ■ Educate relevant staff on the informed consent policy at regular intervals. ■ Train all staff that confirming comprehension is the goal, and it is achieved through a consistent, defined process.
Nerd Newbies (understand the requirement)
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
CHAPTER 10: MEDICAL RECORDS 10.01.16 Informed consent 30.00.11 Surgical informed consent
Nerd Trailblazers (prepare the path for others)
Frequency of the citation: 10.01.16 35%, 30.00.11 29%
Overview of the requirement: The medical records standard focuses on the requirement that medical staff policies identify the procedures and treatments that require informed consent, the process for obtaining it, and the elements that must be included. Medical records document the patient’s informed consent including, at least, the required elements. The surgical informed consent standard requires that the consent form be in the medical record prior to the procedure except in the case of emergency. This standard also requires disclosure of sensitive examinations that may be used for educational or training purposes. Comment on deficiencies: Compliance is assessed primarily through review of informed consent policies and patient medical records. Most deficiencies noted the failure to use simple language for consent forms. Other citations focused on issues with the policy itself or for patients presenting in the ED and transferred to inpatient status.
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