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Heads up on a potential TJC tracer to keep on your radar. It’s patients transferred from an inpatient behavioral health setting to the ER. We frequently see TJC (and also CMS) surveyors select this type of case for a tracer. So, what are the key things they’re looking for?

TJC Tracer: Transfer to ER

At the point of transfer to the ER, surveyors are looking for key pieces of documentation in the record. First, how did the hospital determine the need to transfer the patient to the ER? What was the change in the patient’s condition?

Nursing documentation is critical at this point. It needs to show how you monitored the patient’s condition and made the decision to transfer. Your policy on change in patient condition is also important. Surveyors will look to see if staff followed the policy. For more on this topic, see our post Responding to Changes in a Patient’s Condition.

Second, surveyors will evaluate the transfer process itself. What information did you send with the patient to inform the ER? Who accompanied the patient? How did they do the handoff?

Return to Behavioral Health Setting

Next, a key juncture surveyors evaluate is the point when the patient returns to the BH inpatient setting. Essentially, they are looking for a reassessment of the patient’s physical and mental condition. This should include a basic nursing reassessment (vitals, physical condition, pain, etc.) and a mental status exam.

Many hospitals use a free-form nursing progress note to document this reassessment. However, the best practice we see is a structured template for this type of note.

We have a sample resource we’ve developed for clients. It’s a Post Medical Transfer Nursing Reassessment Progress Note. Nursing staff complete it for patients returning from the ER or from an inpatient stay at a med/surg hospital. It includes the following information:

  • Handoff communication with medical facility
  • Findings & follow-up recommendations from medical facility
  • Nursing reassessment
  • Mental status assessment
  • Indications for change in observation or precaution levels
  • Notification to physician
  • Notification to family/significant other

Discharge from Behavioral Health Setting

Lastly, at the point of discharge, this TJC tracer focuses on inclusion of information in the Discharge Summary. Both TJC and CMS want to see information regarding the ER visit in the Discharge Summary. In addition, they want to see any recommendations for follow-up care after discharge as it relates to the condition that sent the patient to the ER.

The relevant TJC standard is RC.02.04.01 EP 3 – requirements for the Discharge Summary. The relevant CMS standard is B133 in Appendix AA – Discharge Planning and Discharge Summary. Although neither standard references ER visits, we’ve seen citations from both TJC and CMS on this issue and that’s where they cite it.

Survey Feedback

One of our clients recently related their experience with this type of TJC tracer:

“The nurse surveyor asked for the chart of the patient most recently seen at the ER. She had us walk her through the whole process. Why we sent the patient out. How he got to the ER. And how we reassessed him when he came back.

We did OK on the sending out part. But our reassessment when he returned was weak. The nurse did a brief progress note but it wasn’t really a reassessment of the patient’s condition. And there was no documentation that she notified the physician.

We also didn’t put anything about this in the patient’s Discharge Summary. We wound up getting two RFIs. One was for lack of reassessment and the other for not having the information in the Discharge Summary.

As a result, we now use a structured progress note for patients returning from the ER. It includes prompts for the specific information we need. We also put a prompt in our Discharge Summary to ask about ER visits and any follow-up recommendations.”

Barrins & Associates Resources

When we conduct our Mock Surveys and Continuous Readiness Consultations, we always include a tracer on a patient sent out to the ER. We also share our resources on best practices and survey readiness strategies. As always, we’ll continue to keep you posted on TJC and CMS survey readiness and best strategies for ongoing compliance.