diff --git a/.gitea/workflows/atomicai.yml b/.gitea/workflows/atomicai.yml new file mode 100644 index 0000000..2512d02 --- /dev/null +++ b/.gitea/workflows/atomicai.yml @@ -0,0 +1,77 @@ +name: AtomicAI Urgent Care 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 Urgent Care 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 Urgent Care Quality Management. + + ## Your Expertise + - Urgent Care Association (UCA) accreditation standards + - Triage protocols and acuity assessment + - Point-of-care testing (CLIA waived) + - Minor procedure protocols (laceration repair, splinting) + - Occupational medicine and workers comp + - Infection control and isolation procedures + - Transfer protocols for higher acuity patients + - Medication dispensing and prescribing + - Radiology and diagnostic imaging protocols + - Patient flow and wait time optimization + + ## Document Creation Guidelines + - Place Clinical SOPs in SOPs/Clinical/ + - Place Triage Protocols in Protocols/Triage/ + - Place Procedure SOPs in SOPs/Procedures/ + - Place Lab SOPs in SOPs/Laboratory/ + - Place Patient Forms in Forms/Patient/ + - Place Policies in Policies/ + + ## Numbering Convention + - SOP-UC-XXX for Urgent Care SOPs + - SOP-TRI-XXX for Triage SOPs + - SOP-PRO-XXX for Procedure SOPs + - SOP-LAB-XXX for Laboratory SOPs + - POL-XXX for Policies + - FRM-XXX for Forms + + Always create branches and submit changes as Pull Requests for review. + Focus on efficient, high-quality episodic care. + allowed_tools: 'Read,Edit,Grep,Glob,Write' + disallowed_tools: 'Bash,WebSearch' diff --git a/Forms/Discharge-Instructions/.gitkeep b/Forms/Discharge-Instructions/.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/Intake-Forms/FRM-UC-001-Triage-Assessment.md b/Forms/Intake-Forms/FRM-UC-001-Triage-Assessment.md new file mode 100644 index 0000000..a1631f7 --- /dev/null +++ b/Forms/Intake-Forms/FRM-UC-001-Triage-Assessment.md @@ -0,0 +1,270 @@ +# Urgent Care Triage Assessment + +| Form ID | FRM-UC-001 | Revision | 1.0 | +|---------|-------------|----------|-----| + +--- + +## Patient Information + +| Field | Entry | +|-------|-------| +| Patient Name | | +| MRN | | +| Date of Birth | | +| Age | | +| Sex | ☐ Male ☐ Female | +| Date | | +| Time of Arrival | | +| Time of Triage | | + +--- + +## Chief Complaint + +*In patient's own words:* + +**Duration of Symptoms:** + +--- + +## Vital Signs + +| Parameter | Value | Normal? | +|-----------|-------|---------| +| Temperature | °F / °C | ☐ Yes ☐ No | +| Heart Rate | bpm | ☐ Yes ☐ No | +| Respiratory Rate | /min | ☐ Yes ☐ No | +| Blood Pressure | / mmHg | ☐ Yes ☐ No | +| SpO2 | % on ☐ RA ☐ O2 ___L | ☐ Yes ☐ No | +| Pain Score | /10 | | +| Weight | kg / lbs | | +| Blood Glucose (if indicated) | mg/dL | ☐ N/A | + +--- + +## Allergies + +☐ No Known Drug Allergies (NKDA) +☐ No Known Allergies (NKA) + +| Allergen | Type | Reaction | +|----------|------|----------| +| | ☐ Drug ☐ Food ☐ Environmental | | +| | ☐ Drug ☐ Food ☐ Environmental | | +| | ☐ Drug ☐ Food ☐ Environmental | | + +--- + +## Current Medications + +| Medication | Dose | Frequency | +|------------|------|-----------| +| | | | +| | | | +| | | | +| | | | + +--- + +## Brief Medical History + +☐ None significant + +| Condition | Yes | Condition | Yes | +|-----------|-----|-----------|-----| +| Diabetes | ☐ | Heart Disease | ☐ | +| Hypertension | ☐ | Lung Disease/Asthma | ☐ | +| Kidney Disease | ☐ | Liver Disease | ☐ | +| Blood Clots/DVT | ☐ | Cancer | ☐ | +| Seizures | ☐ | Immunocompromised | ☐ | +| Pregnancy | ☐ (LMP: _______) | Other: | ☐ | + +--- + +## History of Present Illness + +### OPQRST + +| Element | Response | +|---------|----------| +| **O**nset: When did this start? | | +| **P**rovocation: What makes it better/worse? | | +| **Q**uality: Describe the symptom | | +| **R**adiation: Does it travel anywhere? | | +| **S**everity: How bad is it (0-10)? | | +| **T**iming: Constant or comes and goes? | | + +### Associated Symptoms + +| Symptom | Present | Symptom | Present | +|---------|---------|---------|---------| +| Fever/Chills | ☐ | Nausea/Vomiting | ☐ | +| Headache | ☐ | Diarrhea | ☐ | +| Shortness of Breath | ☐ | Urinary Symptoms | ☐ | +| Chest Pain | ☐ | Rash | ☐ | +| Dizziness | ☐ | Weakness | ☐ | +| Cough | ☐ | Vision Changes | ☐ | +| Sore Throat | ☐ | Numbness/Tingling | ☐ | + +--- + +## Quick Look Assessment + +### General Appearance + +| Observation | Finding | +|-------------|---------| +| Alert and oriented | ☐ Yes ☐ No | +| In acute distress | ☐ Yes ☐ No | +| Skin color | ☐ Normal ☐ Pale ☐ Flushed ☐ Cyanotic | +| Respiratory effort | ☐ Normal ☐ Labored | +| Ambulation | ☐ Independent ☐ Assisted ☐ Wheelchair ☐ Stretcher | +| Obvious injuries | ☐ None ☐ Present: _______ | + +--- + +## Screening Questions + +### Safety Screens + +| Question | Response | +|----------|----------| +| Fall in past 24 hours? | ☐ Yes ☐ No | +| Head injury? | ☐ Yes ☐ No | +| Loss of consciousness? | ☐ Yes ☐ No | +| Recent surgery? | ☐ Yes (When: _______) ☐ No | +| Recent travel? | ☐ Yes (Where: _______) ☐ No | +| Exposure to COVID-19/illness? | ☐ Yes ☐ No | + +### For Women of Childbearing Age + +| Question | Response | +|----------|----------| +| Could you be pregnant? | ☐ Yes ☐ No ☐ N/A | +| Last menstrual period | | +| Currently breastfeeding? | ☐ Yes ☐ No ☐ N/A | + +--- + +## Red Flag Assessment + +**Check if ANY present (requires immediate provider notification):** + +| Red Flag | Present | +|----------|---------| +| Chest pain/pressure | ☐ | +| Difficulty breathing at rest | ☐ | +| SpO2 <92% | ☐ | +| Severe headache (worst of life) | ☐ | +| Sudden vision loss | ☐ | +| Sudden weakness/numbness | ☐ | +| Speech difficulty | ☐ | +| Facial droop | ☐ | +| Uncontrolled bleeding | ☐ | +| Altered mental status | ☐ | +| Syncope | ☐ | +| Anaphylaxis symptoms | ☐ | +| Suicidal/homicidal ideation | ☐ | + +**If ANY checked → Immediate provider evaluation and consider ED transfer** + +--- + +## Acuity Level Assigned + +☐ **Level 1 - Emergent** (ED Transfer Required) + → Provider/911 notified: Time _______ Name _______ + +☐ **Level 2 - Urgent** (Provider within 15 min) + → Provider notified: Time _______ + +☐ **Level 3 - Semi-Urgent** (Provider within 30 min) + +☐ **Level 4 - Non-Urgent** (Provider within 60 min) + +☐ **Level 5 - Redirect** (Outside UC scope) + → Redirected to: _______ + +--- + +## Interventions Initiated + +| Intervention | Ordered | Completed | +|--------------|---------|-----------| +| Ice pack | ☐ | ☐ | +| Elevation | ☐ | ☐ | +| Wound care | ☐ | ☐ | +| POC glucose | ☐ | ☐ | +| POC UA | ☐ | ☐ | +| POC strep | ☐ | ☐ | +| POC flu/COVID | ☐ | ☐ | +| ECG | ☐ | ☐ | +| Other: | ☐ | ☐ | + +--- + +## Pain Assessment + +| Field | Entry | +|-------|-------| +| Location | | +| Quality | ☐ Sharp ☐ Dull ☐ Aching ☐ Burning ☐ Throbbing | +| Intensity (0-10) | /10 | +| Onset | ☐ Sudden ☐ Gradual | +| Duration | | +| What relieves it? | | +| What worsens it? | | +| Previous episodes? | ☐ Yes ☐ No | + +--- + +## Injury Details (if applicable) + +| Field | Entry | +|-------|-------| +| Mechanism of Injury | | +| Time of Injury | | +| Location of Injury | | +| Tetanus status | ☐ Up to date ☐ Needs update ☐ Unknown | +| Work-related? | ☐ Yes ☐ No | + +--- + +## Additional Notes + +--- + +## Re-Triage (if waiting time extended) + +| Time | Vital Signs | Condition Changed? | New Acuity | Initials | +|------|-------------|-------------------|------------|----------| +| | | ☐ Yes ☐ No | | | +| | | ☐ Yes ☐ No | | | +| | | ☐ Yes ☐ No | | | + +--- + +## Triage Nurse/MA Signature + +| Field | Entry | +|-------|-------| +| Name | | +| Credentials | | +| Signature | | +| Date | | +| Time | | + +--- + +## Provider Acknowledgment + +| Field | Entry | +|-------|-------| +| Provider notified at | (time) | +| Provider seen at | (time) | +| Provider Signature | | + +--- + +*Form FRM-UC-001 Rev 1.0 - Urgent Care Triage Assessment* diff --git a/Forms/POCT-Records/.gitkeep b/Forms/POCT-Records/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Forms/Procedure-Consent/.gitkeep b/Forms/Procedure-Consent/.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/Forms/Triage-Forms/.gitkeep b/Forms/Triage-Forms/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/Forms/Visit-Documentation/.gitkeep b/Forms/Visit-Documentation/.gitkeep new file mode 100644 index 0000000..e69de29 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 6ce0793..04403eb 100644 --- a/README.md +++ b/README.md @@ -1,3 +1,133 @@ -# urgent-care +# Urgent Care & Walk-In Clinic Quality Management System -A comprehensive QMS template designed for urgent care centers, walk-in clinics, and immediate care facilities. \ No newline at end of file +A comprehensive QMS template designed for urgent care centers, walk-in clinics, and immediate care facilities. + +## 🏥 Designed For + +- **Urgent Care Centers** - Walk-in acute care facilities +- **Retail Health Clinics** - Pharmacy-based clinics +- **Occupational Health Clinics** - Workers' comp and employer health +- **After-Hours Clinics** - Extended hour primary care +- **Pediatric Urgent Care** - Children's walk-in services +- **Sports Medicine Clinics** - Athletic injury care +- **Freestanding Emergency Departments** - Stand-alone emergency services + +## 📋 Regulatory Framework + +This template supports compliance with: + +- **The Joint Commission** - Ambulatory Care accreditation +- **UCAOA** - Urgent Care Association standards and benchmarks +- **CMS** - Medicare/Medicaid requirements +- **State Medical Board** - Physician practice and supervision +- **OSHA** - Bloodborne pathogens, workplace safety +- **HIPAA** - Patient privacy requirements +- **CLIA** - Point-of-care testing requirements +- **State Facility Licensing** - Urgent care facility regulations +- **EMTALA** - Emergency screening requirements (if applicable) +- **CDC** - Infection control guidelines + +## Repository Structure + +``` +├── SOPs/ +│ ├── Patient-Flow/ # Triage, registration, rooming, discharge +│ ├── Clinical-Protocols/ # Chief complaint-based treatment pathways +│ ├── Procedures/ # Suturing, splinting, I&D, injections +│ ├── Diagnostics/ # X-ray, lab, POCT procedures +│ ├── Safety/ # Infection control, emergencies, transfers +│ └── General/ # Document control, training, CAPA +├── Forms/ +│ ├── Triage-Forms/ # ESI triage, vital signs, acuity +│ ├── Visit-Documentation/ # History, exam, assessment, plan templates +│ ├── Procedure-Consent/ # Procedure-specific consent forms +│ ├── Discharge-Instructions/# Condition-specific aftercare +│ ├── POCT-Records/ # Point-of-care testing logs +│ └── Training/ # Competency assessments +├── Policies/ # Facility policies +├── Work-Instructions/ # Step-by-step procedures +└── Templates/ # Document templates +``` + +## Document Numbering Convention + +- **POL-XXX**: Policies +- **SOP-PF-XXX**: Patient Flow SOPs +- **SOP-CP-XXX**: Clinical Protocol SOPs +- **SOP-PRC-XXX**: Procedure SOPs +- **SOP-DX-XXX**: Diagnostic SOPs +- **SOP-SAF-XXX**: Safety SOPs +- **WI-XXX**: Work Instructions +- **FRM-XXX**: Forms and Records + +## 🤖 AI-Powered Assistance + +This repository includes **AtomicAI**, your urgent care QMS assistant. Mention `@atomicai` in any issue or pull request to: + +- Draft triage and patient flow procedures +- Create clinical treatment protocols +- Generate procedure SOPs for common urgent care procedures +- Develop discharge instruction templates +- Create emergency transfer protocols +- Review documents for accreditation compliance + +### Example Prompts + +- "@atomicai create an SOP for ESI triage in urgent care" +- "@atomicai draft a laceration repair protocol with suturing technique" +- "@atomicai write a chest pain evaluation and transfer protocol" +- "@atomicai create discharge instructions for ankle sprain" +- "@atomicai develop a point-of-care strep testing procedure" +- "@atomicai create an occupational injury documentation form" + +## Getting Started + +1. **Establish Triage Protocols** - Implement acuity-based patient flow +2. **Define Clinical Pathways** - Create chief complaint-based protocols +3. **Set Up Procedure Standards** - Document common urgent care procedures +4. **Implement POCT Program** - Configure point-of-care testing QC +5. **Train Staff** - Use competency assessment forms + +## Key Documents to Create First + +1. **Triage Protocol** - Acuity assessment and flow decisions +2. **Chest Pain/ACS Protocol** - High-risk complaint management +3. **Laceration Repair SOP** - Wound care and suturing procedure +4. **Fracture/Splinting Protocol** - Immobilization and referral +5. **Transfer to ED Protocol** - Emergency transfer criteria and process +6. **POCT Quality Control SOP** - Point-of-care testing requirements +7. **Discharge Instruction Library** - Condition-specific aftercare + +## Special Considerations for Urgent Care + +### Patient Flow +- Walk-in vs. scheduled appointments +- Triage and acuity assessment +- Wait time management +- Left without being seen (LWBS) tracking +- Throughput optimization + +### Clinical Scope +- Chief complaint-based protocols +- Scope of practice limitations +- Transfer and referral criteria +- High-risk complaint management +- Pediatric-specific considerations + +### Procedures +- Wound care and suturing +- Fracture management and splinting +- Abscess I&D +- Foreign body removal +- Injection techniques + +### Safety and Compliance +- Emergency equipment and medications +- Infection control (isolation, PPE) +- Controlled substance management +- Medical record documentation +- Quality metrics (door-to-provider, LWBS) + +--- + +*This template is maintained by AtomicQMS. For questions, open an issue in this repository.* diff --git a/SOPs/Clinical-Protocols/.gitkeep b/SOPs/Clinical-Protocols/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/SOPs/Diagnostics/.gitkeep b/SOPs/Diagnostics/.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/Patient-Care/SOP-UC-001-Triage-Protocol.md b/SOPs/Patient-Care/SOP-UC-001-Triage-Protocol.md new file mode 100644 index 0000000..db13274 --- /dev/null +++ b/SOPs/Patient-Care/SOP-UC-001-Triage-Protocol.md @@ -0,0 +1,265 @@ +# Standard Operating Procedure: Urgent Care Triage Protocol + +| Document ID | SOP-UC-001 | +|-------------|-------------| +| Title | Urgent Care Patient Triage and Acuity Assessment | +| Revision | 1.0 | +| Effective Date | [DATE] | +| Author | [AUTHOR] | +| Approved By | [APPROVER] | +| Department | Urgent Care | + +--- + +## 1. Purpose + +To establish standardized procedures for triaging patients presenting to urgent care to ensure appropriate prioritization, timely care, and identification of emergent conditions requiring ED transfer. + +## 2. Scope + +This procedure applies to all patients presenting to urgent care including: +- Walk-in patients +- Scheduled same-day appointments +- Patients referred from other providers +- Pediatric and adult patients + +## 3. Responsibilities + +### 3.1 Triage Nurse/Medical Assistant +- Conduct initial patient assessment +- Assign acuity level +- Obtain vital signs +- Identify emergent conditions +- Initiate appropriate protocols + +### 3.2 Urgent Care Provider +- Review triage findings +- Evaluate patients per acuity +- Make disposition decisions +- Authorize ED transfers + +### 3.3 Front Desk Staff +- Check in patients +- Alert clinical staff to arrivals +- Facilitate registration + +## 4. Definitions + +| Term | Definition | +|------|------------| +| Triage | Process of prioritizing patients based on clinical urgency | +| Acuity | Severity of patient's condition | +| ESI | Emergency Severity Index (reference scale) | +| ED Transfer | Patient requiring emergency department level care | +| Chief Complaint | Primary reason for visit | + +## 5. Triage Levels + +### 5.1 Urgent Care Acuity Scale + +| Level | Description | Examples | Target Time | +|-------|-------------|----------|-------------| +| 1 - Emergent | Life/limb threatening, requires ED | Chest pain, stroke symptoms, severe dyspnea | IMMEDIATE ED transfer | +| 2 - Urgent | Significant symptoms, needs prompt attention | High fever, moderate dyspnea, severe pain | <15 minutes | +| 3 - Semi-Urgent | Moderate symptoms, stable | Lacerations, minor fractures, UTI symptoms | <30 minutes | +| 4 - Non-Urgent | Minor symptoms, stable | Minor cold symptoms, prescription refills | <60 minutes | +| 5 - Not Appropriate | Outside scope, needs referral | Chronic disease management, specialist care | Redirect to PCP | + +## 6. Procedure + +### 6.1 Initial Contact + +1. **Patient Arrival** + - Acknowledge patient within 5 minutes of arrival + - Brief visual assessment + - Determine if immediate attention needed + +2. **Quick Look Assessment** + Rapidly evaluate: + - Level of consciousness + - Respiratory effort + - Skin color + - Obvious distress + - Visible injuries + +### 6.2 Triage Assessment + +#### 6.2.1 Chief Complaint + +Document in patient's own words: +- Primary symptom +- Duration +- Severity (0-10 scale for pain) + +#### 6.2.2 Vital Signs + +| Parameter | Normal Adult Range | Action if Abnormal | +|-----------|-------------------|-------------------| +| Temperature | 97.0-99.0°F | Assess for fever source | +| Heart Rate | 60-100 bpm | Assess for underlying cause | +| Respiratory Rate | 12-20/min | Oxygen, escalate if distressed | +| Blood Pressure | <140/90 mmHg | Repeat, assess symptoms | +| SpO2 | ≥95% on RA | Oxygen, consider ED transfer | +| Pain Score | 0/10 | Pain management protocol | + +#### 6.2.3 Brief History + +| Element | Document | +|---------|----------| +| Onset | When did symptoms start? | +| Provocation | What makes it better/worse? | +| Quality | Describe the symptom | +| Radiation | Does pain travel? | +| Severity | Rate 0-10 | +| Time | Constant or intermittent? | +| Medications | Current medications | +| Allergies | Drug and other allergies | +| Last meal | Time of last food/drink | +| Medical history | Relevant conditions | + +### 6.3 Level 1 - Emergent (ED Transfer Required) + +**Immediate recognition and action for:** + +| Condition | Signs/Symptoms | Action | +|-----------|---------------|--------| +| Cardiac emergency | Chest pain, diaphoresis, SOB, arm/jaw pain | Call 911, ECG if available | +| Stroke | Facial droop, arm weakness, speech difficulty | Call 911, note time of onset | +| Respiratory failure | SpO2 <90%, severe distress, cyanosis | Oxygen, call 911 | +| Anaphylaxis | Airway swelling, hypotension, urticaria | Epinephrine, call 911 | +| Severe trauma | Major bleeding, altered consciousness | Stabilize, call 911 | +| Sepsis | Fever, tachycardia, hypotension, AMS | IV access, fluids, call 911 | +| Active seizure | Convulsions, unresponsive | Protect, time seizure, call 911 | + +**ED Transfer Protocol:** +1. Call 911 immediately +2. Notify provider +3. Initiate stabilizing measures +4. Document time and interventions +5. Provide EMS with clinical information +6. Send documentation with patient + +### 6.4 Level 2 - Urgent + +**Requires provider evaluation within 15 minutes:** + +| Condition | Characteristics | +|-----------|----------------| +| High fever | >103°F adult, >102°F child <3 months | +| Moderate respiratory distress | SpO2 92-95%, increased work of breathing | +| Severe pain | 8-10/10 | +| Significant bleeding | Controlled but significant | +| Dehydration with vomiting | Unable to keep fluids down | +| Acute abdominal pain | Severe, localized | +| Altered mental status | Confusion, not baseline | +| Syncope | Recent loss of consciousness | +| Diabetic emergency | Hypoglycemia, ketoacidosis symptoms | + +### 6.5 Level 3 - Semi-Urgent + +**Provider evaluation within 30 minutes:** + +| Condition | Characteristics | +|-----------|----------------| +| Lacerations | Requiring sutures, bleeding controlled | +| Possible fractures | Deformity, point tenderness, stable | +| Moderate pain | 5-7/10 | +| UTI symptoms | Dysuria, frequency, no fever | +| Ear pain | Moderate, no fever | +| Minor burns | <5% BSA, superficial | +| Sprains/strains | Ambulating, stable | +| Rash with mild symptoms | No systemic symptoms | + +### 6.6 Level 4 - Non-Urgent + +**Provider evaluation within 60 minutes:** + +- Upper respiratory symptoms (mild) +- Minor sore throat +- Minor skin conditions +- Medication refills +- Minor eye complaints (non-trauma) +- Minor injuries not requiring sutures + +### 6.7 Level 5 - Redirect + +**Outside urgent care scope:** + +- Chronic disease management +- Routine physical exams +- Mental health crisis (redirect to crisis line/ED) +- Dental emergencies (redirect to dentist/ED) +- Specialty care needs +- Workers' compensation (per facility policy) + +### 6.8 Pediatric Considerations + +#### Age-Specific Concerns + +| Age | Automatic Elevation Criteria | +|-----|------------------------------| +| <3 months | Any fever ≥100.4°F → ED | +| <2 years | Fever >103°F, lethargy, poor feeding → Urgent | +| All pediatric | Respiratory distress, dehydration, altered behavior → Urgent | + +#### Pediatric Vital Sign Norms + +| Age | HR | RR | Systolic BP | +|-----|----|----|-------------| +| Infant | 100-160 | 30-60 | 70-90 | +| 1-3 years | 90-150 | 24-40 | 80-100 | +| 4-6 years | 80-140 | 22-34 | 90-110 | +| 7-12 years | 70-120 | 18-30 | 90-120 | +| >12 years | 60-100 | 12-20 | 100-120 | + +### 6.9 Geriatric Considerations + +- Lower threshold for escalation +- Atypical presentations common +- Consider polypharmacy +- Falls assessment +- Cognitive baseline consideration + +## 7. Documentation + +Complete FRM-UC-001 Triage Assessment including: +- Time of arrival and triage +- Chief complaint +- Vital signs +- Allergies and medications +- Brief history +- Assigned acuity level +- Interventions initiated +- Provider notification time + +## 8. Re-Triage + +Re-assess waiting patients: +- Every 30 minutes for Level 2 +- Every 60 minutes for Level 3-4 +- Immediately if condition changes +- Document all re-assessments + +## 9. Quality Metrics + +| Metric | Target | +|--------|--------| +| Time to triage | <10 minutes | +| Appropriate acuity assignment | >95% (audit) | +| ED transfers identified at triage | >99% | +| Patient complaints re: wait time | <5% | + +## 10. References + +- Emergency Severity Index (ESI) guidelines +- Emergency Nurses Association guidelines +- Pediatric Assessment Triangle +- State nursing practice acts + +--- + +## Revision History + +| Rev | Date | Description | Author | +|-----|------|-------------|--------| +| 1.0 | [DATE] | Initial release | [AUTHOR] | diff --git a/SOPs/Patient-Flow/.gitkeep b/SOPs/Patient-Flow/.gitkeep new file mode 100644 index 0000000..e69de29 diff --git a/SOPs/Procedures/.gitkeep b/SOPs/Procedures/.gitkeep new file mode 100644 index 0000000..e69de29 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] |