During our next Joint Commission visit, nurses will be interviewed about many different aspects of documenting in PeCare (PeC), our electronic health record. Surveyors will want to witness that we are all facile with the application and that our documentation in PeC represents our best practice and is aligned with our policies and procedures.
During a recent mock Joint Commission survey, staff were able to demonstrate to “surveyors” that they could find essential information about the patient such as the Health Care Proxy, initial assessment information and pain reassessments. In specialty areas, staff explained how we use the sedation narrators and in the ED, how we document massive blood transfusions.
Utilizing an electronic multidisciplinary patient Plan of Care is a new skill for all of us and the Joint Commission will certainly want to review how we are using the tool to improve patient outcomes and safety. Over the next few months, as we prepare for the visit, we should all learn from each other so that we are confident in the processes of care, are knowledgeable and are able to articulate that the important elements are carried out safely and are documented appropriately.