Question

You are completing an internship in the Quality Department at General Hospital. As part of your internship, the director of the department has asked you to complete a small quality improvement project utilizing their EHR. The director would like you to determine if randomly selected five charts meet the following criteria: The consent is detailed and addresses the following 8 items: o Permission o Unforseen Conditions o Anesthesia o Specimens o Photographing, Videotaping, etc. o Explanation of Procedure, Risks, Benefits, and Alternatives o Blood Transfusion o No Guarantees and o Blood TransfuioRisks, All signatures required are present o Patient/Relative/Guardian o Physician o Witness

Patient identifying information is blacked out to protect patient privacy. This means that all signatures at the bottom of the page are blacked out, if you see a black box at the signature line this indicates that there is a signature present.

A. Does consent meet all specified criteria?
B. Based on your findings from the 5 charts, what would be a goal for improvement (use the SMART goal format)?

Answer 1

A. Yes. the content met all the required criteria with a brief description of each component and in the way of better understanding of the patient to make health care decisions. The consent also met the required signature of the patient/relative, witness, and doctor's signature.

B. SMART Goal

S - Specific - The consent form should have a clear picture of the required details.

I need to improve the content in the consent form with a clear description of all the details to make an appropriate decision on treatment by the patient.

M - Measurable - The staff should be trained in obtaining proper consent.

I will assess the staff knowledge on the consent form and provide the needed training.

A - Action - Ensure that the patient has been explained thoroughly with the plan of care.

Make discussion with the patient and the staff to ensure the treatment plan.

R - Realistic - Encourage for proper documentation of consent forms.

Records should be maintained properly to improve the standards and quality.

T - Time-Bound - Quality improvement should be attained at the end of the year.

Quality improvement is attained by 90% at the end of the year.