Patient Tracer Summary

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RAFT Task 3
Tracer Patient summary:
A 67year old female patient was scheduled for a laparoscopic hysterectomy. However 5 weeks prior to hospitalization she was hospitalized and the case was converted to an open procedure due to excessive bleeding. After being discharged she developed fever and drainage and was readmitted again for possible postoperative infection seven days ago. On day two of admission she underwent surgery for post operative abscess and insertion for a central line for long-term antibiotics.
She is scheduled to go home with home health providing oversight of antibiotic therapy.

In order to be compliant with Joint Commission standards for Record of care, Treatment and services an assessment was done which is
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The corrective action should include:
· Easy flow of information and reader friendly.
· Typesetting should be professional.
· It should include an overall summary section for team members to review.
· Accreditation requirements must be interwoven in natural flow within the context of the assessment and become more meaningful components to the assessment:

The design of the new form was based on the following research:

· This format would include prompts, interwoven accreditation requirements, and a summary section.
· Nursing topics were grouped together so that it flowed logically together and the nurse only needed to indicate negative exceptions to a healthy assessment. This would also minimize charting and clarify problematic areas in the patient’s assessment. If a section was normal, a quick check box indicating “no problems noted” was provided.
· The form also grouped together the need for financial assistance, need for case management referral, spiritual considerations, suspected abuse and neglect, and assistance at home, as well. Prompt boxes were also designed by these sections because it was the team’s belief that referrals to case management, the business office, and social services were also important in care planning. Such referrals or at least the documentation of the referral, had
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