clinical-inpatient/README.md

# Clinical Inpatient Services Quality Management System

A comprehensive QMS template designed for hospital inpatient units, nursing services, and acute care facilities.

## 🏥 Designed For

- **Medical-Surgical Units** - General inpatient nursing care
- **Intensive Care Units** - ICU, CCU, SICU, MICU
- **Step-Down Units** - Progressive and intermediate care
- **Specialty Units** - Oncology, transplant, cardiac, neuro
- **Rehabilitation Units** - Acute inpatient rehabilitation
- **Observation Units** - Short-stay and clinical decision units
- **Long-Term Acute Care** - LTACH facilities

## 📋 Regulatory Framework

This template supports compliance with:

- **The Joint Commission** - Hospital accreditation standards
- **CMS Conditions of Participation** - Medicare/Medicaid requirements
- **State Hospital Licensing** - State-specific regulations
- **ANA Standards** - American Nurses Association practice standards
- **AACN Standards** - Critical care nursing standards
- **NPSG** - National Patient Safety Goals
- **OSHA** - Occupational safety requirements
- **HIPAA** - Patient privacy requirements
- **CDC/NHSN** - Healthcare-associated infection surveillance
- **Nurse Practice Act** - State-specific nursing regulations

## Repository Structure

```
├── SOPs/
│   ├── Patient-Care/          # Assessment, interventions, documentation
│   ├── Medication-Admin/      # High-alert meds, IV therapy, controlled substances
│   ├── Safety/                # Fall prevention, skin integrity, restraints
│   ├── Infection-Control/     # HAI prevention, isolation, hand hygiene
│   ├── Emergency-Response/    # Code blue, rapid response, emergency protocols
│   └── General/               # Document control, training, CAPA
├── Forms/
│   ├── Assessment-Tools/      # Admission, pain, fall risk, skin assessments
│   ├── Care-Plans/            # Interdisciplinary care plan templates
│   ├── Medication-Records/    # MAR, IV therapy, controlled substance logs
│   ├── Safety-Checklists/     # Hourly rounding, shift handoff, safety huddles
│   ├── Incident-Reports/      # Event reporting, near-miss documentation
│   └── Training/              # Competency assessments
├── Policies/                  # Institutional nursing policies
├── Work-Instructions/         # Step-by-step procedures
└── Templates/                 # Document templates
```

## Document Numbering Convention

- **POL-XXX**: Policies
- **SOP-PC-XXX**: Patient Care SOPs
- **SOP-MED-XXX**: Medication Administration SOPs
- **SOP-SAF-XXX**: Safety SOPs
- **SOP-IC-XXX**: Infection Control SOPs
- **SOP-ER-XXX**: Emergency Response SOPs
- **WI-XXX**: Work Instructions
- **FRM-XXX**: Forms and Records

## 🤖 AI-Powered Assistance

This repository includes **AtomicAI**, your inpatient QMS assistant. Mention `@atomicai` in any issue or pull request to:

- Draft patient care and assessment SOPs
- Create medication administration procedures
- Generate fall prevention and safety protocols
- Develop infection control procedures
- Create emergency response workflows
- Review documents for Joint Commission compliance

### Example Prompts

- "@atomicai create an SOP for central line insertion and maintenance"
- "@atomicai draft a high-alert medication double-check procedure"
- "@atomicai write a fall prevention bundle protocol"
- "@atomicai create a CLABSI prevention checklist"
- "@atomicai develop a rapid response team activation procedure"
- "@atomicai create a restraint assessment and monitoring protocol"

## Getting Started

1. **Align with Hospital Policies** - Ensure consistency with institutional requirements
2. **Customize Assessment Tools** - Adapt forms for your patient population
3. **Set Up Safety Protocols** - Implement fall prevention and skin care bundles
4. **Establish Medication Safety** - Configure high-alert medication procedures
5. **Train Staff** - Use competency assessment forms

## Key Documents to Create First

1. **Admission Assessment SOP** - Standardized patient intake process
2. **Medication Administration Policy** - Five rights, high-alert drugs
3. **Fall Prevention Protocol** - Risk assessment and interventions
4. **Pressure Injury Prevention** - Braden scale, turning schedules
5. **Shift Handoff Communication** - SBAR or standardized handoff tool
6. **Rapid Response Activation** - Criteria and escalation procedures
7. **Central Line Care Bundle** - CLABSI prevention protocol

## Special Considerations for Inpatient Care

### Patient Assessment
- Comprehensive admission assessment
- Ongoing reassessment frequency
- Pain assessment and management
- Fall risk stratification (Morse, Hendrich)
- Skin integrity (Braden scale)

### Medication Safety
- High-alert medication protocols
- Look-alike/sound-alike medications
- Independent double-check requirements
- Controlled substance management
- IV compatibility and administration

### Patient Safety
- Two-patient-identifier verification
- Hourly rounding programs
- Bed alarm and fall precautions
- Restraint use and monitoring
- Suicide risk assessment

### Infection Prevention
- Hand hygiene compliance
- Isolation precautions by type
- Central line bundle (CLABSI)
- Catheter care (CAUTI prevention)
- Surgical site infection prevention

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*This template is maintained by AtomicQMS. For questions, open an issue in this repository.*