July 12

Representatives from The Joint Commission are on-site this week at UNC Hospitals. They are touring the Hospitals throughout the week and speaking with our employees as part of our triennial survey. Joint Commission Surveyors will be wearing a Joint Commission name badge and will always be accompanied by a hospital employee wearing a name badge. The following is an update from Laura Harmon, Director of Accreditation, to UNC Health Care managers and physicians.

Joint Commission update
Following are issues noted by Joint Commission surveyors. Please share this information with your staff, in preparation for a surveyor visit to your area:


  1. Do not use prohibited abbreviations.  For example, instead of "qd", write out "daily."
  2. Patient consent forms need to be dated and timed by all parties: the patient, the physician, and the witness.
  3. All medical record entries, such as physician orders and progress notes, need to be authenticated by the author, and include a date and time.
  4. Any pain medication order should include an indication for use, such as the patient's pain level on the 1 to 10 scale.
  5. Review the hospital's policy on Medication Reconciliation. Clinicians should be prepared to speak to how inpatient admission and discharge medication reconciliation is performed.
  6. "Time out" before procedures must be documented in the physician's note.
  7. Prior to a procedure, an updated history and physical is required, and a statement that the patient was re-examined must be included as well as the results of the exam: no change vs. changes.


The survey will conclude Friday, July 15.