diff --git a/.gitea/workflows/atomicai.yml b/.gitea/workflows/atomicai.yml new file mode 100644 index 0000000..b094f5f --- /dev/null +++ b/.gitea/workflows/atomicai.yml @@ -0,0 +1,76 @@ +name: AtomicAI Clinical Inpatient Assistant + +on: + issue_comment: + types: [created] + issues: + types: [opened, assigned] + pull_request: + types: [opened, synchronize, assigned] + pull_request_review_comment: + types: [created] + +jobs: + claude-assistant: + runs-on: ubuntu-latest + if: | + github.actor != 'atomicqms-service' && + ( + (github.event_name == 'issue_comment' && contains(github.event.comment.body, '@atomicai')) || + (github.event_name == 'issues' && github.event.action == 'opened' && contains(github.event.issue.body, '@atomicai')) || + (github.event_name == 'pull_request' && github.event.action == 'opened' && contains(github.event.pull_request.body, '@atomicai')) || + (github.event_name == 'pull_request_review_comment' && contains(github.event.comment.body, '@atomicai')) || + (github.event.action == 'assigned' && github.event.assignee.login == 'atomicai') + ) + + permissions: + contents: write + issues: write + pull-requests: write + + steps: + - uses: actions/checkout@v4 + with: + fetch-depth: 0 + + - name: Run AtomicAI Clinical Inpatient Assistant + uses: https://beta.atomicqms.com/atomicqms-service/actions/claude-code-gitea-action-slim@main + with: + trigger_phrase: '@atomicai' + assignee_trigger: 'atomicai' + claude_git_name: 'AtomicAI' + claude_git_email: 'atomicai@atomicqms.local' + custom_instructions: | + You are AtomicAI, an AI assistant specialized in Clinical Inpatient Quality Management. + + ## Your Expertise + - Hospital accreditation standards (Joint Commission, DNV) + - Inpatient care protocols and clinical pathways + - Patient safety and fall prevention + - Infection control and hospital-acquired conditions + - Medication administration and reconciliation + - Code Blue and rapid response procedures + - Discharge planning and transitions of care + - Nursing documentation standards + - CMS Conditions of Participation + + ## Document Creation Guidelines + - Place Clinical SOPs in SOPs/Clinical/ + - Place Nursing SOPs in SOPs/Nursing/ + - Place Safety SOPs in SOPs/Safety/ + - Place Emergency Protocols in Protocols/Emergency/ + - Place Patient Forms in Forms/Patient/ + - Place Policies in Policies/ + + ## Numbering Convention + - SOP-IP-XXX for Inpatient SOPs + - SOP-NUR-XXX for Nursing SOPs + - SOP-SAF-XXX for Safety SOPs + - PRO-EMR-XXX for Emergency Protocols + - POL-XXX for Policies + - FRM-XXX for Forms + + Always create branches and submit changes as Pull Requests for review. + Prioritize patient safety and regulatory compliance. + allowed_tools: 'Read,Edit,Grep,Glob,Write' + disallowed_tools: 'Bash,WebSearch' diff --git a/Forms/Assessment-Tools/.gitkeep b/Forms/Assessment-Tools/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Forms/Assessment-Tools/FRM-INP-001-Nursing-Admission-Assessment.md b/Forms/Assessment-Tools/FRM-INP-001-Nursing-Admission-Assessment.md new file mode 100644 index 0000000..fdcfbf4 --- /dev/null +++ b/Forms/Assessment-Tools/FRM-INP-001-Nursing-Admission-Assessment.md @@ -0,0 +1,332 @@ +# Nursing Admission Assessment + +| Form ID | FRM-INP-001 | Revision | 1.0 | +|---------|-------------|----------|-----| + +--- + +## Patient Information + +| Field | Entry | +|-------|-------| +| Patient Name | | +| MRN | | +| Date of Birth | | +| Admission Date | | +| Admission Time | | +| Admitting Physician | | +| Unit/Room | | +| Admitting Diagnosis | | +| Source of Admission | ☐ Home ☐ ED ☐ Transfer ☐ Other: _______ | +| Mode of Arrival | ☐ Ambulatory ☐ Wheelchair ☐ Stretcher | + +--- + +## Vital Signs + +| Parameter | Value | Time | +|-----------|-------|------| +| Temperature | °F / °C | | +| Heart Rate | bpm | | +| Respiratory Rate | breaths/min | | +| Blood Pressure | / mmHg | | +| SpO2 | % on ☐ RA ☐ O2 ___L/min | | +| Pain Level | /10 | | +| Height | | | +| Weight | | | + +--- + +## Allergies + +☐ No Known Allergies (NKA) +☐ No Known Drug Allergies (NKDA) + +| Allergen | Type | Reaction | +|----------|------|----------| +| | ☐ Drug ☐ Food ☐ Environmental ☐ Other | | +| | ☐ Drug ☐ Food ☐ Environmental ☐ Other | | +| | ☐ Drug ☐ Food ☐ Environmental ☐ Other | | + +**Allergy band applied?** ☐ Yes ☐ N/A + +--- + +## Current Medications + +| Medication | Dose | Frequency | Last Taken | Continue? | +|------------|------|-----------|------------|-----------| +| | | | | ☐ Yes ☐ No | +| | | | | ☐ Yes ☐ No | +| | | | | ☐ Yes ☐ No | +| | | | | ☐ Yes ☐ No | +| | | | | ☐ Yes ☐ No | +| | | | | ☐ Yes ☐ No | +| | | | | ☐ Yes ☐ No | +| | | | | ☐ Yes ☐ No | + +**Medication source:** ☐ Patient/Family ☐ Pharmacy Records ☐ PCP Records ☐ Other: _______ + +**Medications brought to hospital?** ☐ Yes (inventory attached) ☐ No + +--- + +## Medical History + +### Past Medical History +☐ None significant + +| Condition | Notes | +|-----------|-------| +| ☐ Hypertension | | +| ☐ Diabetes | Type: ☐ 1 ☐ 2 | +| ☐ Heart Disease | | +| ☐ COPD/Asthma | | +| ☐ Stroke/TIA | | +| ☐ Cancer | Type: | +| ☐ Kidney Disease | | +| ☐ Liver Disease | | +| ☐ Seizures | | +| ☐ Psychiatric | | +| ☐ Other: | | + +### Past Surgical History +☐ None + +| Surgery/Procedure | Year | +|-------------------|------| +| | | +| | | +| | | + +--- + +## Review of Systems + +### General +- ☐ Fatigue/Weakness +- ☐ Fever/Chills +- ☐ Weight Change +- ☐ Night Sweats + +### Cardiovascular +- ☐ Chest Pain +- ☐ Palpitations +- ☐ Edema +- ☐ Shortness of Breath with Activity + +### Respiratory +- ☐ Cough +- ☐ Shortness of Breath at Rest +- ☐ Oxygen Use at Home +- ☐ CPAP/BiPAP Use + +### Gastrointestinal +- ☐ Nausea/Vomiting +- ☐ Abdominal Pain +- ☐ Diarrhea +- ☐ Constipation +- ☐ Blood in Stool + +### Genitourinary +- ☐ Incontinence +- ☐ Dysuria +- ☐ Urgency/Frequency +- ☐ Foley Catheter + +### Neurological +- ☐ Numbness/Tingling +- ☐ Weakness +- ☐ Confusion +- ☐ Dizziness/Vertigo + +### Skin +- ☐ Rash +- ☐ Open Wounds +- ☐ Bruising + +--- + +## Pain Assessment + +| Field | Entry | +|-------|-------| +| Pain Present? | ☐ Yes ☐ No | +| Location | | +| Character | ☐ Sharp ☐ Dull ☐ Aching ☐ Burning ☐ Stabbing | +| Intensity (0-10) | | +| Duration | ☐ Constant ☐ Intermittent | +| Aggravating Factors | | +| Relieving Factors | | +| Current Pain Management | | + +--- + +## Fall Risk Assessment + +**Morse Fall Scale** (or institutional tool) + +| Risk Factor | Score | +|-------------|-------| +| History of falling | ☐ No (0) ☐ Yes (25) | +| Secondary diagnosis | ☐ No (0) ☐ Yes (15) | +| Ambulatory aid | ☐ None/Bed rest/Nurse assist (0) ☐ Crutches/Cane/Walker (15) ☐ Furniture (30) | +| IV/Heparin Lock | ☐ No (0) ☐ Yes (20) | +| Gait | ☐ Normal/Bed rest/Immobile (0) ☐ Weak (10) ☐ Impaired (20) | +| Mental Status | ☐ Oriented to own ability (0) ☐ Overestimates/forgets limitations (15) | +| **Total Score** | | + +**Risk Level:** +- ☐ Low Risk (0-24) +- ☐ Moderate Risk (25-44) +- ☐ High Risk (≥45) + +**Fall precautions initiated?** ☐ Yes ☐ N/A + +--- + +## Pressure Ulcer Risk Assessment + +**Braden Scale** + +| Category | Score (1-4) | +|----------|-------------| +| Sensory Perception | | +| Moisture | | +| Activity | | +| Mobility | | +| Nutrition | | +| Friction/Shear | | +| **Total Score** | | + +**Risk Level:** +- ☐ Mild Risk (15-18) +- ☐ Moderate Risk (13-14) +- ☐ High Risk (10-12) +- ☐ Very High Risk (≤9) + +**Skin interventions initiated?** ☐ Yes ☐ N/A + +--- + +## Skin Assessment + +☐ Skin intact, no abnormalities noted + +**Abnormalities (document location and description):** + +| Location | Description | Size | Stage/Type | +|----------|-------------|------|------------| +| | | | | +| | | | | + +--- + +## Nutritional Screen + +| Field | Entry | +|-------|-------| +| Diet at Home | | +| Recent Weight Loss? | ☐ Yes (____lbs in ____weeks) ☐ No | +| Difficulty Swallowing? | ☐ Yes ☐ No | +| Dentures? | ☐ Yes ☐ No | +| Food Allergies/Intolerances | | +| Special Diet Needs | | + +**Dietitian Referral Needed?** ☐ Yes ☐ No + +--- + +## Functional Assessment + +### Mobility +- ☐ Independent +- ☐ Assistive Device: _______ +- ☐ Requires Assistance +- ☐ Bed Bound + +### Activities of Daily Living + +| Activity | Independent | Needs Assistance | Dependent | +|----------|-------------|------------------|-----------| +| Bathing | ☐ | ☐ | ☐ | +| Dressing | ☐ | ☐ | ☐ | +| Toileting | ☐ | ☐ | ☐ | +| Feeding | ☐ | ☐ | ☐ | +| Transfers | ☐ | ☐ | ☐ | + +--- + +## Psychosocial Assessment + +| Field | Entry | +|-------|-------| +| Living Situation | ☐ Alone ☐ With Family/Spouse ☐ Assisted Living ☐ SNF ☐ Other: _______ | +| Primary Caregiver | | +| Emergency Contact | | +| Contact Phone | | +| Relationship | | +| Barriers to Care | ☐ None ☐ Language ☐ Transportation ☐ Financial ☐ Other: _______ | +| Interpreter Needed? | ☐ Yes (Language: _______) ☐ No | + +--- + +## Advance Directives + +| Field | Entry | +|-------|-------| +| Advance Directive on File? | ☐ Yes ☐ No ☐ Unknown | +| Healthcare Proxy/POA? | ☐ Yes (Name: _______) ☐ No | +| Copy Obtained? | ☐ Yes ☐ No ☐ N/A | +| Code Status | ☐ Full Code ☐ DNR ☐ DNR/DNI ☐ Comfort Care Only | +| Physician Order for Code Status? | ☐ Yes ☐ Pending | + +--- + +## Discharge Planning Screen + +| Field | Entry | +|-------|-------| +| Anticipated Discharge Disposition | ☐ Home ☐ Home with Services ☐ Rehab ☐ SNF ☐ Unknown | +| DME Needs Anticipated? | ☐ Yes ☐ No ☐ Unknown | +| Home Health Needs? | ☐ Yes ☐ No ☐ Unknown | +| Case Management Referral? | ☐ Yes ☐ No | +| Social Work Referral? | ☐ Yes ☐ No | + +--- + +## Safety Measures Initiated + +- [ ] Fall precautions per risk level +- [ ] Skin precautions per risk level +- [ ] Call light within reach +- [ ] Bed in low position +- [ ] Side rails per policy +- [ ] Patient education on safety + +--- + +## Orientation Provided + +- [ ] Room orientation (call light, bathroom, bed controls) +- [ ] Visiting hours +- [ ] Unit phone number +- [ ] Patient rights information +- [ ] Advance directive information +- [ ] Valuables policy + +--- + +## Assessment Completion + +| Field | Entry | +|-------|-------| +| Assessment Completed By | | +| Credentials | | +| Date | | +| Time | | +| Signature | | + +--- + +*Form FRM-INP-001 Rev 1.0 - Nursing Admission Assessment* diff --git a/Forms/Care-Plans/.gitkeep b/Forms/Care-Plans/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Forms/FRM-001-Document-Change-Request.md b/Forms/FRM-001-Document-Change-Request.md new file mode 100644 index 0000000..55c718a --- /dev/null +++ b/Forms/FRM-001-Document-Change-Request.md @@ -0,0 +1,64 @@ +# Document Change Request Form + +| Form ID | FRM-001 | Revision | 1.0 | +|---------|---------|----------|-----| + +--- + +## Section 1: Request Information + +| Field | Entry | +|-------|-------| +| Request Date | | +| Requested By | | +| Department | | + +## Section 2: Document Information + +| Field | Entry | +|-------|-------| +| Document Number | | +| Document Title | | +| Current Revision | | + +## Section 3: Change Description + +### Type of Change +- [ ] New Document +- [ ] Revision to Existing Document +- [ ] Document Obsolescence + +### Description of Change +*(Describe the proposed change in detail)* + + + + +### Reason for Change +*(Explain why this change is needed)* + + + + +## Section 4: Impact Assessment + +### Affected Areas +- [ ] Training Required +- [ ] Other Documents Affected +- [ ] Process Changes Required +- [ ] Validation Impact + +### List Affected Documents + + +## Section 5: Approvals + +| Role | Name | Signature | Date | +|------|------|-----------|------| +| Requester | | | | +| Document Owner | | | | +| Quality Assurance | | | | + +--- + +*Form FRM-001 Rev 1.0* diff --git a/Forms/FRM-003-CAPA-Form.md b/Forms/FRM-003-CAPA-Form.md new file mode 100644 index 0000000..6790a8f --- /dev/null +++ b/Forms/FRM-003-CAPA-Form.md @@ -0,0 +1,91 @@ +# Corrective and Preventive Action (CAPA) Form + +| Form ID | FRM-003 | Revision | 1.0 | +|---------|---------|----------|-----| + +--- + +## Section 1: CAPA Identification + +| Field | Entry | +|-------|-------| +| CAPA Number | | +| Date Initiated | | +| Initiated By | | +| CAPA Owner | | +| Target Closure Date | | + +## Section 2: Classification + +### Type +- [ ] Corrective Action +- [ ] Preventive Action + +### Source +- [ ] Customer Complaint +- [ ] Internal Audit +- [ ] External Audit +- [ ] Process Deviation +- [ ] Nonconforming Product +- [ ] Management Review +- [ ] Other: ____________ + +### Priority +- [ ] Critical (5 business days) +- [ ] Major (15 business days) +- [ ] Minor (30 business days) + +## Section 3: Problem Description + +*(Describe the nonconformity or potential nonconformity)* + + + + +## Section 4: Immediate Containment + +*(Actions taken to contain the immediate impact)* + + + + +## Section 5: Root Cause Investigation + +### Investigation Method Used +- [ ] 5 Whys +- [ ] Fishbone Diagram +- [ ] Fault Tree Analysis +- [ ] Other: ____________ + +### Root Cause Determination + + + + +## Section 6: Corrective/Preventive Actions + +| Action | Responsible | Due Date | Status | +|--------|-------------|----------|--------| +| | | | | +| | | | | +| | | | | + +## Section 7: Effectiveness Verification + +| Criteria | Method | Result | +|----------|--------|--------| +| | | | + +Verification Date: ____________ +Verified By: ____________ + +## Section 8: Closure + +| Role | Name | Signature | Date | +|------|------|-----------|------| +| CAPA Owner | | | | +| Quality Approval | | | | + +--- + +*Form FRM-003 Rev 1.0* diff --git a/Forms/FRM-006-Audit-Checklist.md b/Forms/FRM-006-Audit-Checklist.md new file mode 100644 index 0000000..45bf0b6 --- /dev/null +++ b/Forms/FRM-006-Audit-Checklist.md @@ -0,0 +1,56 @@ +# Internal Audit Checklist + +| Form ID | FRM-006 | Revision | 1.0 | +|---------|---------|----------|-----| + +--- + +## Audit Information + +| Field | Entry | +|-------|-------| +| Audit Number | | +| Audit Date | | +| Area/Process Audited | | +| Lead Auditor | | +| Auditee(s) | | + +--- + +## Checklist Items + +| # | Requirement/Question | Reference | C/NC/NA | Evidence/Notes | +|---|---------------------|-----------|---------|----------------| +| 1 | Are current versions of applicable procedures available? | SOP-001 | | | +| 2 | Are personnel trained on applicable procedures? | SOP-003 | | | +| 3 | Are training records current and complete? | SOP-003 | | | +| 4 | Are records properly maintained and retrievable? | SOP-001 | | | +| 5 | Are nonconformities being documented and addressed? | SOP-002 | | | +| 6 | Are CAPAs being completed on time? | SOP-002 | | | +| 7 | Is equipment calibrated and maintained? | | | | +| 8 | Are process controls being followed? | | | | +| 9 | Are quality objectives being monitored? | | | | +| 10 | | | | | + +**Legend:** C = Conforming, NC = Nonconforming, NA = Not Applicable + +--- + +## Findings Summary + +| Finding # | Type | Description | Clause Reference | +|-----------|------|-------------|------------------| +| | | | | +| | | | | + +--- + +## Auditor Signature + +| Auditor | Signature | Date | +|---------|-----------|------| +| | | | + +--- + +*Form FRM-006 Rev 1.0* diff --git a/Forms/Incident-Reports/.gitkeep b/Forms/Incident-Reports/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Forms/Medication-Records/.gitkeep b/Forms/Medication-Records/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Forms/Safety-Checklists/.gitkeep b/Forms/Safety-Checklists/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Forms/Training/FRM-004-Training-Record.md b/Forms/Training/FRM-004-Training-Record.md new file mode 100644 index 0000000..b66164d --- /dev/null +++ b/Forms/Training/FRM-004-Training-Record.md @@ -0,0 +1,72 @@ +# Training Record Form + +| Form ID | FRM-004 | Revision | 1.0 | +|---------|---------|----------|-----| + +--- + +## Section 1: Employee Information + +| Field | Entry | +|-------|-------| +| Employee Name | | +| Employee ID | | +| Department | | +| Job Title | | + +## Section 2: Training Information + +| Field | Entry | +|-------|-------| +| Training Title | | +| Training Date | | +| Training Duration | | +| Trainer Name | | +| Trainer Qualification | | + +### Training Type +- [ ] Initial Training +- [ ] Retraining +- [ ] Refresher +- [ ] Procedure Update + +### Delivery Method +- [ ] Classroom +- [ ] On-the-Job +- [ ] Self-Study +- [ ] Computer-Based +- [ ] Other: ____________ + +## Section 3: Training Content + +*(List topics covered or attach training materials)* + + + + +## Section 4: Assessment + +### Assessment Method +- [ ] Written Test +- [ ] Practical Demonstration +- [ ] Verbal Assessment +- [ ] Observation + +### Assessment Results + +| Metric | Result | +|--------|--------| +| Score (if applicable) | | +| Pass/Fail | | + +## Section 5: Signatures + +| Role | Name | Signature | Date | +|------|------|-----------|------| +| Trainee | | | | +| Trainer | | | | +| Supervisor | | | | + +--- + +*Form FRM-004 Rev 1.0* diff --git a/Policies/POL-001-Quality-Policy.md b/Policies/POL-001-Quality-Policy.md new file mode 100644 index 0000000..ebd85dd --- /dev/null +++ b/Policies/POL-001-Quality-Policy.md @@ -0,0 +1,57 @@ +# Quality Policy + +| Document ID | POL-001 | +|-------------|---------| +| Title | Quality Policy | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | + +--- + +## 1. Policy Statement + +[ORGANIZATION NAME] is committed to providing products and services that consistently meet customer requirements and applicable regulatory requirements. We strive for continual improvement of our Quality Management System to enhance customer satisfaction. + +## 2. Quality Objectives + +Our organization commits to: + +1. **Customer Focus**: Understanding and meeting customer needs and expectations +2. **Regulatory Compliance**: Maintaining compliance with all applicable regulations and standards +3. **Continuous Improvement**: Continually improving the effectiveness of our QMS +4. **Employee Engagement**: Ensuring all employees understand their role in quality +5. **Risk-Based Thinking**: Identifying and addressing risks and opportunities + +## 3. Management Commitment + +Top management demonstrates commitment to the QMS by: + +- Ensuring the quality policy is appropriate to the organization's purpose +- Ensuring quality objectives are established and compatible with strategic direction +- Ensuring integration of QMS requirements into business processes +- Promoting the use of the process approach and risk-based thinking +- Ensuring resources needed for the QMS are available +- Communicating the importance of effective quality management +- Ensuring the QMS achieves its intended results +- Engaging, directing, and supporting persons to contribute to QMS effectiveness + +## 4. Scope + +This policy applies to all employees, contractors, and processes within the scope of our Quality Management System. + +## 5. Communication + +This policy shall be: +- Communicated and understood within the organization +- Available to relevant interested parties as appropriate +- Reviewed for continuing suitability + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/README.md b/README.md index 38806ce..dd4d70e 100644 --- a/README.md +++ b/README.md @@ -1,3 +1,133 @@ -# clinical-inpatient +# Clinical Inpatient Services Quality Management System -A comprehensive QMS template designed for hospital inpatient units, nursing services, and acute care facilities. \ No newline at end of file +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 + +--- + +*This template is maintained by AtomicQMS. For questions, open an issue in this repository.* diff --git a/SOPs/Emergency-Response/.gitkeep b/SOPs/Emergency-Response/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/SOPs/General/SOP-001-Document-Control.md b/SOPs/General/SOP-001-Document-Control.md new file mode 100644 index 0000000..b64ef52 --- /dev/null +++ b/SOPs/General/SOP-001-Document-Control.md @@ -0,0 +1,112 @@ +# Standard Operating Procedure: Document Control + +| Document ID | SOP-001 | +|-------------|---------| +| Title | Document Control | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Quality Assurance | + +--- + +## 1. Purpose + +To establish a procedure for the creation, review, approval, distribution, and control of documents within the Quality Management System. + +## 2. Scope + +This procedure applies to all controlled documents including: +- Policies +- Standard Operating Procedures (SOPs) +- Work Instructions +- Forms and Templates +- Specifications +- External documents of external origin + +## 3. Responsibilities + +### 3.1 Document Owner +- Responsible for document content and accuracy +- Initiates document creation and revision +- Ensures periodic review is performed + +### 3.2 Quality Assurance +- Maintains the document control system +- Assigns document numbers +- Manages document distribution +- Archives obsolete documents + +### 3.3 Approvers +- Review and approve documents before release +- Ensure documents are adequate for intended purpose + +## 4. Procedure + +### 4.1 Document Creation + +1. Identify the need for a new document +2. Request document number from Quality Assurance +3. Draft document using appropriate template +4. Include all required header information +5. Submit for review and approval + +### 4.2 Document Review and Approval + +1. Route document to appropriate reviewers +2. Reviewers provide comments within 5 business days +3. Author addresses all comments +4. Final approval by designated approver +5. Quality Assurance releases document + +### 4.3 Document Numbering + +Documents shall be numbered according to the following convention: + +| Type | Prefix | Example | +|------|--------|---------| +| Policy | POL | POL-001 | +| SOP | SOP | SOP-001 | +| Work Instruction | WI | WI-001 | +| Form | FRM | FRM-001 | + +### 4.4 Revision Control + +1. All changes require documented justification +2. Changes follow same review/approval process as new documents +3. Revision number increments with each approved change +4. Revision history maintained in document footer + +### 4.5 Document Distribution + +1. Current versions available in document control system +2. Obsolete versions marked and archived +3. Training on new/revised documents as needed + +### 4.6 Periodic Review + +1. Documents reviewed at least every 2 years +2. Review documented even if no changes made +3. Reviews may result in revision or reaffirmation + +## 5. Related Documents + +- FRM-001 Document Change Request Form +- FRM-002 Document Review Record + +## 6. Definitions + +| Term | Definition | +|------|------------| +| Controlled Document | Document managed under document control system | +| Obsolete | Document no longer valid for use | +| Revision | Updated version of a document | + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/General/SOP-002-CAPA.md b/SOPs/General/SOP-002-CAPA.md new file mode 100644 index 0000000..8dace85 --- /dev/null +++ b/SOPs/General/SOP-002-CAPA.md @@ -0,0 +1,134 @@ +# Standard Operating Procedure: Corrective and Preventive Action (CAPA) + +| Document ID | SOP-002 | +|-------------|---------| +| Title | Corrective and Preventive Action | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Quality Assurance | + +--- + +## 1. Purpose + +To establish a systematic process for identifying, investigating, correcting, and preventing nonconformities and potential nonconformities. + +## 2. Scope + +This procedure applies to: +- Product and process nonconformities +- Customer complaints +- Audit findings +- Process deviations +- Potential nonconformities identified through risk analysis + +## 3. Definitions + +| Term | Definition | +|------|------------| +| Corrective Action | Action to eliminate the cause of a detected nonconformity | +| Preventive Action | Action to eliminate the cause of a potential nonconformity | +| Root Cause | Fundamental reason for a nonconformity | +| Effectiveness Check | Verification that implemented actions achieved desired results | + +## 4. Responsibilities + +### 4.1 CAPA Owner +- Investigates the issue +- Identifies root cause +- Develops and implements corrective/preventive actions +- Verifies effectiveness + +### 4.2 Quality Assurance +- Manages CAPA system +- Assigns CAPA numbers +- Tracks CAPA status +- Reviews and approves CAPAs +- Reports CAPA metrics to management + +### 4.3 Management +- Provides resources for CAPA implementation +- Reviews CAPA trends +- Ensures timely closure + +## 5. Procedure + +### 5.1 CAPA Initiation + +1. Identify nonconformity or potential nonconformity +2. Document issue on CAPA Form (FRM-003) +3. Classify severity and priority +4. Assign CAPA owner + +### 5.2 Investigation + +1. Gather relevant data and evidence +2. Interview personnel involved +3. Review related documents and records +4. Use appropriate investigation tools: + - 5 Whys + - Fishbone Diagram + - Failure Mode Analysis + +### 5.3 Root Cause Analysis + +1. Identify potential root causes +2. Verify root cause through evidence +3. Document root cause determination +4. Consider systemic implications + +### 5.4 Action Development + +1. Develop corrective/preventive actions +2. Assign responsibilities and due dates +3. Assess actions for: + - Appropriateness to problem severity + - Impact on other processes + - Resource requirements + +### 5.5 Implementation + +1. Execute approved actions +2. Document implementation evidence +3. Update affected documents/processes +4. Provide training as needed + +### 5.6 Effectiveness Verification + +1. Define effectiveness criteria +2. Allow sufficient time for actions to take effect +3. Collect and analyze data +4. Document verification results +5. If ineffective, reopen CAPA for further action + +### 5.7 Closure + +1. Review all CAPA documentation +2. Verify all actions completed +3. Confirm effectiveness verified +4. Obtain approval for closure + +## 6. CAPA Metrics + +Quality Assurance shall track and report: +- Number of open CAPAs +- CAPA aging +- On-time closure rate +- Effectiveness rate +- CAPAs by category/source + +## 7. Related Documents + +- FRM-003 CAPA Form +- SOP-003 Nonconforming Product Control +- SOP-004 Customer Complaints + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/General/SOP-003-Training.md b/SOPs/General/SOP-003-Training.md new file mode 100644 index 0000000..22538c1 --- /dev/null +++ b/SOPs/General/SOP-003-Training.md @@ -0,0 +1,123 @@ +# Standard Operating Procedure: Training and Competence + +| Document ID | SOP-003 | +|-------------|---------| +| Title | Training and Competence | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Human Resources / Quality | + +--- + +## 1. Purpose + +To ensure personnel performing work affecting product quality are competent based on appropriate education, training, skills, and experience. + +## 2. Scope + +This procedure applies to: +- All employees performing quality-affecting activities +- Contractors and temporary personnel +- Personnel requiring GxP training + +## 3. Responsibilities + +### 3.1 Supervisors/Managers +- Identify training needs for their personnel +- Ensure training is completed before performing tasks +- Evaluate competence of personnel +- Maintain department training records + +### 3.2 Human Resources +- Coordinate training programs +- Maintain central training database +- Track training compliance +- Archive training records + +### 3.3 Quality Assurance +- Develop QMS-related training +- Approve training curricula for GxP activities +- Audit training compliance + +### 3.4 Employees +- Complete assigned training on time +- Maintain current qualifications +- Report training needs to supervisor + +## 4. Procedure + +### 4.1 Training Needs Assessment + +1. Identify competence requirements for each role +2. Document requirements in job descriptions +3. Assess current competence of personnel +4. Identify training gaps + +### 4.2 Training Curriculum Development + +1. Define learning objectives +2. Develop training materials +3. Identify delivery method: + - Classroom + - On-the-job + - Self-study + - Computer-based +4. Define assessment criteria +5. Obtain approval from Quality (for GxP training) + +### 4.3 Training Delivery + +1. Schedule training session +2. Document attendance +3. Deliver training per curriculum +4. Assess comprehension through: + - Written test (minimum 80% passing) + - Practical demonstration + - Supervisor observation + +### 4.4 Training Documentation + +Training records shall include: +- Employee name and ID +- Training title and date +- Trainer name and qualifications +- Assessment results +- Signatures + +### 4.5 Retraining Requirements + +Retraining is required when: +- Significant document revisions occur +- Performance deficiencies identified +- Extended absence from job function +- Periodic requalification due + +### 4.6 New Employee Orientation + +All new employees shall complete: +1. Company orientation +2. Quality system overview +3. Job-specific training +4. SOP read and understand for applicable procedures + +## 5. Training Records Retention + +- Training records maintained for duration of employment +- Records retained 3 years after employee departure +- Records available for regulatory inspection + +## 6. Related Documents + +- FRM-004 Training Record Form +- FRM-005 Training Assessment Form +- Job Descriptions + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/General/SOP-004-Internal-Audit.md b/SOPs/General/SOP-004-Internal-Audit.md new file mode 100644 index 0000000..749d6a5 --- /dev/null +++ b/SOPs/General/SOP-004-Internal-Audit.md @@ -0,0 +1,136 @@ +# Standard Operating Procedure: Internal Audit + +| Document ID | SOP-004 | +|-------------|---------| +| Title | Internal Audit | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Quality Assurance | + +--- + +## 1. Purpose + +To establish a systematic approach for conducting internal audits to verify the effectiveness of the Quality Management System. + +## 2. Scope + +This procedure covers: +- QMS process audits +- Compliance audits +- Product audits +- System audits + +## 3. Definitions + +| Term | Definition | +|------|------------| +| Audit | Systematic, independent examination to determine conformance | +| Auditor | Person qualified to perform audits | +| Finding | Observation of conformance or nonconformance | +| Observation | Noted item not rising to level of finding | + +## 4. Responsibilities + +### 4.1 Lead Auditor +- Plans and schedules audits +- Prepares audit checklists +- Conducts audit activities +- Reports audit findings + +### 4.2 Quality Manager +- Maintains audit program +- Qualifies auditors +- Reviews audit reports +- Reports to management + +### 4.3 Auditee +- Provides access to areas/records +- Responds to findings +- Implements corrective actions + +## 5. Procedure + +### 5.1 Annual Audit Schedule + +1. Develop annual audit schedule considering: + - Previous audit results + - Process criticality + - Regulatory requirements + - Changes to processes +2. Ensure all QMS processes audited at least annually +3. Obtain management approval +4. Communicate schedule to affected areas + +### 5.2 Auditor Qualification + +Auditors shall: +- Complete auditor training course +- Conduct at least 2 audits under supervision +- Be independent of area being audited +- Maintain competence through ongoing audits + +### 5.3 Audit Preparation + +1. Review applicable procedures and standards +2. Review previous audit reports +3. Prepare audit checklist +4. Notify auditee of audit scope and schedule +5. Confirm auditor availability + +### 5.4 Conducting the Audit + +1. Hold opening meeting with auditee +2. Execute audit checklist +3. Gather objective evidence: + - Document review + - Personnel interviews + - Process observation +4. Document findings with evidence +5. Classify findings: + - Major Nonconformance + - Minor Nonconformance + - Observation +6. Hold closing meeting + +### 5.5 Audit Reporting + +1. Complete audit report within 5 business days +2. Report shall include: + - Audit scope and criteria + - Personnel interviewed + - Findings with evidence + - Recommendations +3. Distribute report to auditee and management + +### 5.6 Finding Resolution + +1. Auditee responds with corrective action plan within 10 business days +2. Quality reviews and approves plan +3. Auditee implements corrective actions +4. Auditor verifies effectiveness +5. Close finding upon verification + +## 6. Audit Records + +Maintain for 5 years: +- Audit schedules +- Checklists +- Reports +- Corrective action records + +## 7. Related Documents + +- FRM-006 Audit Checklist Template +- FRM-007 Audit Report Template +- SOP-002 CAPA + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/General/SOP-005-Management-Review.md b/SOPs/General/SOP-005-Management-Review.md new file mode 100644 index 0000000..dd82006 --- /dev/null +++ b/SOPs/General/SOP-005-Management-Review.md @@ -0,0 +1,114 @@ +# Standard Operating Procedure: Management Review + +| Document ID | SOP-005 | +|-------------|---------| +| Title | Management Review | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Quality Assurance | + +--- + +## 1. Purpose + +To ensure top management reviews the Quality Management System at planned intervals to ensure its continuing suitability, adequacy, and effectiveness. + +## 2. Scope + +This procedure applies to the periodic management review of the QMS, including all processes and quality objectives. + +## 3. Frequency + +Management reviews shall be conducted: +- At least annually +- More frequently if significant changes occur +- As needed based on quality performance + +## 4. Responsibilities + +### 4.1 Quality Manager +- Prepares management review agenda and materials +- Facilitates the meeting +- Documents meeting minutes and action items +- Tracks completion of action items + +### 4.2 Top Management +- Attends management review meetings +- Reviews QMS performance data +- Makes decisions on QMS improvements +- Allocates resources as needed + +### 4.3 Department Managers +- Provides input data for their areas +- Attends management review +- Implements assigned action items + +## 5. Management Review Inputs + +The following shall be considered: + +### 5.1 Actions from Previous Reviews +- Status of action items +- Effectiveness of implemented actions + +### 5.2 Changes in Context +- Internal changes (organization, resources) +- External changes (regulations, market) + +### 5.3 QMS Performance +- Customer satisfaction and feedback +- Quality objectives achievement +- Process performance metrics +- Nonconformities and corrective actions +- Audit results +- Supplier performance + +### 5.4 Resource Adequacy +- Personnel +- Infrastructure +- Work environment + +### 5.5 Risk and Opportunities +- Risk assessment results +- Effectiveness of risk controls +- New opportunities identified + +### 5.6 Improvement Opportunities +- Process improvements +- Product improvements +- QMS enhancements + +## 6. Management Review Outputs + +Decisions and actions related to: +- Improvement of QMS and processes +- Product improvement +- Resource needs +- Changes to quality policy or objectives + +## 7. Documentation + +### 7.1 Meeting Minutes +- Date and attendees +- Items discussed +- Decisions made +- Action items with owners and due dates + +### 7.2 Record Retention +- Management review records retained for 5 years +- Available for regulatory inspection + +## 8. Related Documents + +- FRM-008 Management Review Agenda Template +- FRM-009 Management Review Minutes Template + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/Infection-Control/.gitkeep b/SOPs/Infection-Control/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/SOPs/Medication-Admin/.gitkeep b/SOPs/Medication-Admin/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/SOPs/Patient-Care/.gitkeep b/SOPs/Patient-Care/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/SOPs/Patient-Care/SOP-INP-001-Admission-Discharge.md b/SOPs/Patient-Care/SOP-INP-001-Admission-Discharge.md new file mode 100644 index 0000000..fbf4b9d --- /dev/null +++ b/SOPs/Patient-Care/SOP-INP-001-Admission-Discharge.md @@ -0,0 +1,264 @@ +# Standard Operating Procedure: Patient Admission and Discharge + +| Document ID | SOP-INP-001 | +|-------------|-------------| +| Title | Inpatient Admission and Discharge Process | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Patient Care Services | + +--- + +## 1. Purpose + +To establish standardized procedures for the admission and discharge of inpatients to ensure safe, efficient transitions of care and compliance with regulatory requirements. + +## 2. Scope + +This procedure applies to all inpatient admissions and discharges including: +- Elective admissions +- Emergency admissions +- Transfers from other facilities +- Same-day discharges +- Transfer to other levels of care + +## 3. Responsibilities + +### 3.1 Admitting Staff +- Complete registration and insurance verification +- Assign appropriate bed based on admission type +- Communicate with receiving unit + +### 3.2 Nursing Staff +- Conduct admission assessment +- Implement physician orders +- Complete discharge education +- Ensure safe handoff + +### 3.3 Attending Physician +- Complete admission orders +- Document admission H&P +- Authorize discharge +- Complete discharge summary + +### 3.4 Case Management/Social Work +- Assess discharge needs +- Coordinate post-acute care +- Arrange equipment and services + +## 4. Definitions + +| Term | Definition | +|------|------------| +| Admission | Formal entry into inpatient status with expectation of overnight stay | +| Observation | Outpatient status with close monitoring (not admission) | +| Discharge | Formal release from inpatient care | +| Readmission | Return to inpatient status within 30 days of prior discharge | + +## 5. Procedure + +### 5.1 Admission Process + +#### 5.1.1 Pre-Admission (Elective) +1. **Scheduling** + - Confirm surgery/procedure date + - Verify insurance authorization + - Complete pre-admission testing as ordered + +2. **Pre-Admission Call** + - Review arrival instructions + - Confirm medication list + - Review NPO requirements + - Verify transportation plans + +#### 5.1.2 Emergency Admission +1. **ED Assessment Complete** + - Stabilization and workup completed + - Admission decision made by physician + - Bed request placed + +2. **Bed Assignment** + - Match patient needs to unit capabilities + - Consider isolation requirements + - Prioritize by acuity + +#### 5.1.3 Registration and Consent +1. **Patient Registration** + - Verify demographic information + - Confirm insurance/payer + - Issue identification band + - Provide patient rights information + +2. **Consent** + - General consent for treatment + - HIPAA acknowledgment + - Advance directive inquiry + - Specific procedure consents as applicable + +#### 5.1.4 Nursing Admission Assessment + +| Assessment Component | Documentation | +|---------------------|---------------| +| Vital signs | T, HR, RR, BP, SpO2, Pain | +| Allergies | Drug, food, environmental, reactions | +| Current medications | Name, dose, frequency, last taken | +| Medical/surgical history | Complete review | +| Chief complaint | Current presentation | +| Fall risk | Validated tool score | +| Pressure ulcer risk | Braden or similar scale | +| Nutritional screen | Weight, recent changes, intake | +| Pain assessment | Intensity, quality, location | +| Functional status | ADLs, mobility, cognition | +| Psychosocial | Social support, barriers | + +3. **Safety Checks** + - [ ] Fall risk interventions implemented + - [ ] Allergies documented and visible + - [ ] Appropriate ID band (allergy band if indicated) + - [ ] Code status verified and documented + - [ ] Valuables secured + +#### 5.1.5 Physician Admission Orders +Required elements: +- [ ] Diagnosis/reason for admission +- [ ] Level of care +- [ ] Diet orders +- [ ] Activity orders +- [ ] Vital sign frequency +- [ ] Medication orders (reconciled) +- [ ] IV fluids (if applicable) +- [ ] Labs and tests +- [ ] Consults +- [ ] VTE prophylaxis +- [ ] Nursing orders + +### 5.2 Discharge Process + +#### 5.2.1 Discharge Planning +**Initiate at Admission:** +- Anticipated length of stay +- Likely discharge disposition +- Early identification of barriers +- Case management referral if complex needs + +**Ongoing Assessment:** +- Daily review of discharge readiness +- Multidisciplinary rounds participation +- Family/caregiver engagement + +#### 5.2.2 Discharge Criteria +Patient must meet all applicable criteria: +- [ ] Medical condition stable or appropriately managed +- [ ] Discharge orders written by physician +- [ ] Patient/caregiver education completed +- [ ] Medications available/filled +- [ ] Follow-up appointments scheduled +- [ ] Post-acute care arranged (if needed) +- [ ] Transportation arranged +- [ ] Patient/caregiver verbalize understanding + +#### 5.2.3 Medication Reconciliation +1. **Compare Lists** + - Pre-admission medications + - Inpatient medications + - Discharge medications + +2. **Reconciliation Actions** + - Continued unchanged + - Dose changed + - New medication + - Discontinued (with reason) + +3. **Patient Education** + - New medications explained + - Changes to existing medications explained + - Written medication list provided + - Teach-back confirmed + +#### 5.2.4 Discharge Education + +**Required Topics:** +| Topic | Completed | Patient Verbalized Understanding | +|-------|-----------|----------------------------------| +| Diagnosis/condition | ☐ | ☐ | +| Medications | ☐ | ☐ | +| Activity restrictions | ☐ | ☐ | +| Diet restrictions | ☐ | ☐ | +| Wound/device care | ☐ | ☐ | +| Warning signs to watch for | ☐ | ☐ | +| When to call doctor | ☐ | ☐ | +| When to seek emergency care | ☐ | ☐ | +| Follow-up appointments | ☐ | ☐ | + +#### 5.2.5 Discharge Documentation + +**Discharge Summary** (by physician): +- Admission diagnosis and reason +- Hospital course summary +- Significant findings +- Procedures performed +- Discharge diagnosis +- Discharge condition +- Discharge plan and instructions +- Follow-up care + +**Nursing Discharge Note:** +- Discharge date and time +- Mode of transport +- Condition at discharge +- Patient/family understanding confirmed +- Discharge supplies/equipment provided +- Prescriptions given +- Follow-up appointments confirmed + +### 5.3 Special Situations + +#### 5.3.1 Against Medical Advice (AMA) +1. Physician discusses risks with patient +2. Document patient capacity to make decision +3. Attempt to address patient concerns +4. Complete AMA form if patient insists +5. Provide discharge instructions despite AMA status +6. Offer follow-up options + +#### 5.3.2 Transfer to Another Facility +1. Accepting facility and physician confirmed +2. Complete transfer summary +3. Send copies of relevant records +4. Ensure safe transport +5. Call report to receiving unit + +## 6. Documentation + +- FRM-INP-001 Admission Assessment +- FRM-INP-002 Discharge Checklist +- Medication Reconciliation Form +- AMA Discharge Form (if applicable) +- Transfer Summary (if applicable) + +## 7. Quality Metrics + +| Metric | Target | +|--------|--------| +| Admission assessment completed within 8 hours | >95% | +| Discharge instructions documented | 100% | +| Medication reconciliation completed | 100% | +| 30-day readmission rate | Per benchmark | +| Patient satisfaction with discharge | Per benchmark | + +## 8. References + +- CMS Conditions of Participation +- The Joint Commission Standards +- State licensing regulations +- Institutional policies + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/Safety/.gitkeep b/SOPs/Safety/.gitkeep new file mode 100644 index 0000000..dcf2c80 --- /dev/null +++ b/SOPs/Safety/.gitkeep @@ -0,0 +1 @@ +# Placeholder diff --git a/Templates/SOP-Template.md b/Templates/SOP-Template.md new file mode 100644 index 0000000..2e9f35e --- /dev/null +++ b/Templates/SOP-Template.md @@ -0,0 +1,62 @@ +# Standard Operating Procedure: [Title] + +| Document ID | SOP-XXX | +|-------------|---------| +| Title | [Title] | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | [DEPARTMENT] | + +--- + +## 1. Purpose + +[State the purpose of this procedure] + +## 2. Scope + +[Define the scope and applicability] + +## 3. Responsibilities + +### 3.1 [Role 1] +- [Responsibility] +- [Responsibility] + +### 3.2 [Role 2] +- [Responsibility] +- [Responsibility] + +## 4. Definitions + +| Term | Definition | +|------|------------| +| | | + +## 5. Procedure + +### 5.1 [Section Title] + +[Procedure steps] + +### 5.2 [Section Title] + +[Procedure steps] + +## 6. Related Documents + +- [List related procedures, forms, etc.] + +## 7. References + +- [External standards, regulations, etc.] + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/Work Instructions/WI-001-Template.md b/Work Instructions/WI-001-Template.md new file mode 100644 index 0000000..68167f1 --- /dev/null +++ b/Work Instructions/WI-001-Template.md @@ -0,0 +1,68 @@ +# Work Instruction: [Title] + +| Document ID | WI-001 | +|-------------|--------| +| Title | [Title] | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | [DEPARTMENT] | + +--- + +## 1. Purpose + +[Describe the purpose of this work instruction] + +## 2. Scope + +[Define what activities this instruction covers] + +## 3. Safety Precautions + +- [List any safety requirements] +- [Personal protective equipment needed] +- [Hazards to be aware of] + +## 4. Equipment/Materials Required + +| Item | Specification | +|------|---------------| +| | | +| | | + +## 5. Procedure + +### Step 1: [Title] +[Detailed instructions] + +### Step 2: [Title] +[Detailed instructions] + +### Step 3: [Title] +[Detailed instructions] + +## 6. Acceptance Criteria + +[Define what constitutes successful completion] + +## 7. Records + +| Record | Location | Retention | +|--------|----------|-----------| +| | | | + +## 8. References + +- [Related SOPs] +- [Specifications] +- [Standards] + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] |