134 lines
5.3 KiB
Markdown
134 lines
5.3 KiB
Markdown
# Clinical Inpatient Services Quality Management System
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A comprehensive QMS template designed for hospital inpatient units, nursing services, and acute care facilities.
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## 🏥 Designed For
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- **Medical-Surgical Units** - General inpatient nursing care
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- **Intensive Care Units** - ICU, CCU, SICU, MICU
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- **Step-Down Units** - Progressive and intermediate care
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- **Specialty Units** - Oncology, transplant, cardiac, neuro
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- **Rehabilitation Units** - Acute inpatient rehabilitation
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- **Observation Units** - Short-stay and clinical decision units
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- **Long-Term Acute Care** - LTACH facilities
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## 📋 Regulatory Framework
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This template supports compliance with:
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- **The Joint Commission** - Hospital accreditation standards
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- **CMS Conditions of Participation** - Medicare/Medicaid requirements
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- **State Hospital Licensing** - State-specific regulations
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- **ANA Standards** - American Nurses Association practice standards
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- **AACN Standards** - Critical care nursing standards
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- **NPSG** - National Patient Safety Goals
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- **OSHA** - Occupational safety requirements
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- **HIPAA** - Patient privacy requirements
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- **CDC/NHSN** - Healthcare-associated infection surveillance
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- **Nurse Practice Act** - State-specific nursing regulations
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## Repository Structure
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```
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├── SOPs/
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│ ├── Patient-Care/ # Assessment, interventions, documentation
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│ ├── Medication-Admin/ # High-alert meds, IV therapy, controlled substances
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│ ├── Safety/ # Fall prevention, skin integrity, restraints
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│ ├── Infection-Control/ # HAI prevention, isolation, hand hygiene
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│ ├── Emergency-Response/ # Code blue, rapid response, emergency protocols
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│ └── General/ # Document control, training, CAPA
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├── Forms/
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│ ├── Assessment-Tools/ # Admission, pain, fall risk, skin assessments
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│ ├── Care-Plans/ # Interdisciplinary care plan templates
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│ ├── Medication-Records/ # MAR, IV therapy, controlled substance logs
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│ ├── Safety-Checklists/ # Hourly rounding, shift handoff, safety huddles
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│ ├── Incident-Reports/ # Event reporting, near-miss documentation
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│ └── Training/ # Competency assessments
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├── Policies/ # Institutional nursing policies
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├── Work-Instructions/ # Step-by-step procedures
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└── Templates/ # Document templates
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```
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## Document Numbering Convention
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- **POL-XXX**: Policies
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- **SOP-PC-XXX**: Patient Care SOPs
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- **SOP-MED-XXX**: Medication Administration SOPs
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- **SOP-SAF-XXX**: Safety SOPs
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- **SOP-IC-XXX**: Infection Control SOPs
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- **SOP-ER-XXX**: Emergency Response SOPs
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- **WI-XXX**: Work Instructions
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- **FRM-XXX**: Forms and Records
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## 🤖 AI-Powered Assistance
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This repository includes **AtomicAI**, your inpatient QMS assistant. Mention `@atomicai` in any issue or pull request to:
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- Draft patient care and assessment SOPs
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- Create medication administration procedures
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- Generate fall prevention and safety protocols
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- Develop infection control procedures
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- Create emergency response workflows
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- Review documents for Joint Commission compliance
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### Example Prompts
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- "@atomicai create an SOP for central line insertion and maintenance"
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- "@atomicai draft a high-alert medication double-check procedure"
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- "@atomicai write a fall prevention bundle protocol"
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- "@atomicai create a CLABSI prevention checklist"
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- "@atomicai develop a rapid response team activation procedure"
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- "@atomicai create a restraint assessment and monitoring protocol"
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## Getting Started
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1. **Align with Hospital Policies** - Ensure consistency with institutional requirements
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2. **Customize Assessment Tools** - Adapt forms for your patient population
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3. **Set Up Safety Protocols** - Implement fall prevention and skin care bundles
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4. **Establish Medication Safety** - Configure high-alert medication procedures
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5. **Train Staff** - Use competency assessment forms
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## Key Documents to Create First
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1. **Admission Assessment SOP** - Standardized patient intake process
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2. **Medication Administration Policy** - Five rights, high-alert drugs
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3. **Fall Prevention Protocol** - Risk assessment and interventions
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4. **Pressure Injury Prevention** - Braden scale, turning schedules
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5. **Shift Handoff Communication** - SBAR or standardized handoff tool
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6. **Rapid Response Activation** - Criteria and escalation procedures
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7. **Central Line Care Bundle** - CLABSI prevention protocol
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## Special Considerations for Inpatient Care
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### Patient Assessment
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- Comprehensive admission assessment
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- Ongoing reassessment frequency
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- Pain assessment and management
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- Fall risk stratification (Morse, Hendrich)
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- Skin integrity (Braden scale)
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### Medication Safety
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- High-alert medication protocols
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- Look-alike/sound-alike medications
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- Independent double-check requirements
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- Controlled substance management
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- IV compatibility and administration
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### Patient Safety
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- Two-patient-identifier verification
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- Hourly rounding programs
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- Bed alarm and fall precautions
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- Restraint use and monitoring
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- Suicide risk assessment
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### Infection Prevention
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- Hand hygiene compliance
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- Isolation precautions by type
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- Central line bundle (CLABSI)
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- Catheter care (CAUTI prevention)
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- Surgical site infection prevention
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---
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*This template is maintained by AtomicQMS. For questions, open an issue in this repository.*
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