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

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

Key Documents to Create First

Admission Assessment SOP - Standardized patient intake process
Medication Administration Policy - Five rights, high-alert drugs
Fall Prevention Protocol - Risk assessment and interventions
Pressure Injury Prevention - Braden scale, turning schedules
Shift Handoff Communication - SBAR or standardized handoff tool
Rapid Response Activation - Criteria and escalation procedures
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.

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