의료기관 컴플라이언스 11개 항목
Advance Directives & Informed Consent Audit
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Audit of advance directive and informed consent practices covering inquiry and documentation of directives, patient rights notice, informed consent elements, and surrogate decision-making.
Patient Self-Determination ActCMS 42 CFR 482.13(b)42 CFR 489.102TJC RI.01.05.01
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Advance Directive Inquiry & Notice
- Is each adult patient asked at admission whether they have an advance directive, and is the response documented in the record? *
- Is written information provided about the patient's rights under state law to make health care decisions and formulate advance directives? *
- Is care provided without conditioning it on whether the patient has executed an advance directive? *
Directive Documentation & Honoring
- Is a copy of the advance directive (living will, healthcare power of attorney, POLST/MOLST) placed in the medical record? *
- Is code status clearly documented and accessible to the care team, with orders reflecting the directive? *
- Are staff educated on honoring advance directives and community education provided as required? *
Informed Consent Elements
- Does informed consent document the nature of the procedure, material risks, benefits, and reasonable alternatives? *
- Is the consent signed by the patient or authorized representative and the practitioner, and dated before the procedure? *
- Are language and communication needs addressed (interpreter services) so consent is truly informed? *
Surrogate & Capacity
- When a patient lacks decision-making capacity, is the authorized surrogate identified per state law and documented? *
- Is a capacity assessment documented when there is a question about the patient's ability to consent? *
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