SDS Accreditation Update

Legible, well-organized records aid compliance

Neatness, standard abbreviations a must

Because the National Patient Safety Goals from the Joint Commission on Accreditation of Healthcare Organizations emphasize clear communication between caregivers, pay attention
to the legibility of your records, says Suzanne Fornelli, RN, BSN, administrator of The Surgery Center at Southwoods in Youngstown, OH.

"Our surveyor focused on legibility and said that if records could not be read, nurses could not interpret orders correctly," she says.

Correct interpretation does not apply to handwriting only, Fornelli points out. "The surveyor complimented us on our shortened list of standardized abbreviations we allow for charting purposes," she says.

Everyone on her staff has a list of approved abbreviations, and the list also is posted on a 4-foot by 8-foot bulletin board that lists all of the patient safety goals and the center’s policies that help them achieve the goals, she adds.

Sometimes the surveyor is not just looking for a certain type of documentation, but also wants it in a certain place, says Gudrun Anderson, RN, administrator of Gateway Surgery Center in Phoenix.

"Our surveyor was very policy- and documentation-oriented and brought up that all diagnostic summary sheets should be at the front of the chart," she says.

Although she has worked for more than 10 years in ambulatory surgery and has undergone at least four surveys by the Wilmette, IL-based Accreditation Association of Ambulatory Health Care (AAAHC), this was the first time a surveyor mentioned this requirement, Anderson adds.

"I think this is a good example of how surveyors do bring their personal experience and interests to each survey," she adds.

Sources

For more information about recent survey experiences, contact:

  • Suzanne Fornelli, RN, BSN, Administrator, The Surgery Center at Southwoods, 7525 California Ave., Youngstown, OH 44512. Telephone: (330) 758-1954.
  • Gudrun Anderson, RN, Administrator, Gateway Surgery Center, 690 N. Cofco Center Court, Suite 150, Phoenix, AZ 85008. Telephone: (602) 288-4441.