Tracer Record Review - Outpatient Only
updated: 3/21/2016
Data Definition Tool
The Tracer Packet is to be completed in each outpatient area by the manager or designee on a monthly basis. It is suggested
that the manager does not complete a packet for his/her own area. Tracers are due on the last day of the month following the
review (example: July Tracer due July 31).
Instructions: Indicate Yes, No, NA (Not Applicable)
for each question below.
Outpatient Units: Monitor at least 1 patient record per
Standard
month using the Tracer Record Review Outpatient
Tool.
ADMISSION
1 Medical Record Number:
2 Functional screen complete
PC.01.02.01
EP 4;
PC.01.02.03
EP 8
3 If functional screen positive, plans for follow-up
PC.01.02.01
documented
EP 4
Location
YES
VMG Clinic Intake
Form
Activities of Daily Living
section completed.
VMG Assesssment &
Follow-up for Positive
Intake Screen in PT,
OT, ST sections.
Positive screen follow up
documented on form;
NA=negative screen or preexisting condition (i.e., blind,
cerebral palsy, or ADHD)
4 Nutritional screen complete
PC.01.02.01, EP VMG Clinic Intake
4; PC.01.02.03 Form
EP 7
5 If nutritional screen positive, plans for follow-up
documented.
PC. 01.02.01 EP VMG Assesssment & Positive screen follow up
4;
Follow-up for Postive documented on form ; or
Intake Screen
negative screen = NA
6 Pain screen complete
PC.01.02.07
EP 1 & 2
VMG Clinic Intake
Form
Nutritional screen completed.
Pain screen completed
7 If pain screen positive, plans for follow-up documented PC.01.02.01
EP 23;
PC.01.02.07
EP 3
8 Abuse screen complete
PC.01.02.09
EP 4
9 If abuse screen positive, plans for follow-up
PC.01.02.09
documented
EP5, 6, & 7
VMG Assesssment & Positive screen (option C and
Follow-up for Postive >3) follow up documented on
Intake Screen.
form; or negative screen = NA
VMG Clinic Intake
Form
VMG Assesssment &
Follow-up for Postive
Intake Screen.
Social Environment screen
completed.
Positive screen follow up
documented on form; or
negative screen = NA
10 Falls screen complete
PC.01.02.08
EP 1
11 If falls screen positive, plans for follow-up documented PC.01.02.08
EP 2
12 Learning needs/education screen complete
PC.02.03.01
EP 1, 4 & 5
13 If education screen positive, plans for follow-up
PC.02.03.01
documented
EP 10
VMG Assessment &
Follow-up.
VMG Assessment &
Follow-up.
VMG Clinic Intake
Form.
VMG Assessment &
Follow-up
14 Preferred language for discussing health care
documented.
PC.02.01.21
EP 1
VMG Clinic Intake
Form and the
Starpanel outpatient
white board
Falls screen completed for
pts >/= 65 yrs.
Positive screen follow-up
documented on form.
Educational screen
completed.
Positive screen follow-up
documented on form or
negative screen = NA
Documented
RC.02.01.07
EP 2
RC.02.01.07
EP 3
StarPanel - click on
Problem list.
StarPanel - click on
Problem list.
PC.02.03.01
VMG Assesssment & All teaching fields are
Follow-up for Positive completed as appropriate.
Intake Screen
PROBLEM LIST (OP Only)
15 Complete (diagnoses, procedures, allergies, meds)
16 Updated at every physician visit
PATIENT EDUCATION
17 All "teaching" fields complete, as appropriate
(excluding pain management)
All component fields are
completed in StarPanel.
Date of problem list matches
most current physician visit.
18 Documentation by all disciplines, involved in the
patient's care, treatment, or services.
PC.02.03.01
EP 5
Same as above.
Paper and individual
discipline notes
Signature(s) & initials are
present for appropriate
disciplines.
MEDICATION ADMINISTRATION
19 "Do Not Use" Abbreviations are NOT found in the MR
on date of review?
IM.02.02.01
EP 3
No " Do Not Use"
abbreviations are found in the
medical record on the date of
review.
20 Supporting documentation (diagnosis, condition, or
indication) for every order for "current" medications.
MM.04.01.01
EP 9
All entries in the
medical record on
date of review
including medication
orders, problem list,
flowsheets, progress
notes,etc.
Physician orders,
H&P, progress notes
21 Order present for each medication administered.
RC.02.01.01
EP 2
22 Are orders for PRN medications specific such that
there is no therapeutic duplicatoin (multiple options for
a specific indication?
StarPanel:
medication
administration;
progress notes
Medications list
Diagnosis, condition or
indications for use are
documented.
Order present.
Review patient's current PRN
medication orders for
therapeutic duplication. There
should not be two orders that
have the same instructions
for when to administer (e.g.,
prn pain, prn nausea, prn for
agitation).
OPERATIVE & OTHER PROCEDURES
23
RI.01.03.01
Consent form present and signed, dated and timed.
EP 13
24 Type of sedation/anesthesia included on consent form. RI.01.03.01
EP 13
Consent Form
Consent form/
Anesthesia Care
Record
Form completed, signed,
dated, and timed.
Type of sedation/anesthesia
consent is documented
25 Provider history and physical (H&P) completed and
documented prior to procedure?
PC.01.02.03
EP5;
H& P form
H&P on record prior to
procedure/surgery and w/in
appropriate timeframes:
PC.03.01.03
EP 4
On sedation form
Documented
(May use previous H&P documented within 30 days
prior or 24 hours after admission or registration that
includes an update. The update includes an
examination and any changes to the patient's
condition.)
26 Pre-procedural education documented before
operative or high-risk procedures or before moderate
or deep sedation or anesthesia.
27 Patient's conditionis re-evaluated before administering PC.03.01.03
moderate or deep sedation.
EP 8
Sedation & Analgesia ASA class and Pre-Sedation
Record, Anesthesia status completed for
record
moderate or deep sedation.
28 Pre-Procedure Checklist is completed?
Pre-procedure
checklist
Area specific
documentation
systems.
Sedation/Analgesia
form
29 "Time Out" documented before procedure.
UP.01.01.01
EP 2
UP.01.03.01
EP 5
All fields completed, as
appropriate.
Completed including date and
time.
30 Immediate Post Operative/procedural Note is present RC.02.01.03
EP 7
and includes the following:
1. Name of surgeon, proceduralist and assistants;
2. Procedure(s) performed and description of the
procedure;
3. Findings
4. Estimated blood loss;
5. Specimen(s) removed, if any.
6. Postoperative diagnosis;
Post surgical
progress notes
All elements are documented
in the record before the
patient moves to the next
level of care irregardless of
physical location.
NA=Operative/Procedural
report completed before the
patient is transferred to the
next level of care or if the
proceduralist accompanies
the patient from the
procedure room to the next
level of care, the note can be
written in that unit or area of
care.
31 The Operative/Procedural report is dictated or
electronically entered in the pt record within 24 hrs of
the procedure and includes:
1. Patient’s name and unit number;
2. Date of procedure;
3. Name of surgeon, proceduralists and assistants;
4. Pre-operative diagnosis,
5. Postoperative diagnosis;
6. Anesthetic agent used;
7. Description of the techniques and procedure;
8. Description of the findings;
9. Estimated blood loss;
7. Specimen(s) removed, if any;
8. Any laboratory or diagnostic procedure ordered;
9. Complications, if any;
10. Condition of patient.
Surgical / procedure
Report
All elements are documented
in the report and dictated or
electronically entered within
24 hours of the procedure.
The attending physician has
signed the report within 14
days of the procedure.
RC.02.01.03
EP 5 & 6
CMS.482.51.(b)
32 For operative or high-risk procedures and/or the
administration of moderate or deep sedation or
anesthesia, patients are discharged from recovery
area by LIP or by criteria. (Procedural Areas)
33 Discharge instructions form present and complete
34 Patients who receive sedation or anesthesia are
discharged in the company of an individual who
accepts responsibility for the patient.
PC.03.01.07
EP 4
Discharge criteria
documentation.
Discharge criteria
documenation
PC.04.01.05
EP 8
PC.03.01.07
EP 6
Discharge instruction Form completed, dated, and
form
timed.
On sedation form
Documentation present.