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.