Patient MG-4400, 50M — community-acquired pneumonia with septic shock
18 of 18 points observed
Individual patient tracer — acute medical admission · Dr. Miriam Haddad
Surveyor Tracer Final Report
Official Joint Commission International accreditation tracer summary
Patient MG-4400, 50M — community-acquired pneumonia with septic shock
Individual patient tracer — acute medical admission · Emergency
- Point Compliance
- 82%
- 17 checkpoints scored
- Findings Raised
- 1
- Actionable deficit citations
- Surveyor Sign-off
- Dr. Miriam Haddad
- Attested 2026-09-14
Chapter Compliance Telemetry
Standard adherence computed across all observed checkpoints for this trace
- ASC1 checkpoint1 gap0%
- FMS1 checkpointClean50%
- QPS1 checkpointClean50%
- IPSG6 checkpoints1 gap75%
- ACC4 checkpointsClean88%
- AOP2 checkpointsClean100%
- SQE1 checkpointClean100%
- PFR1 checkpointClean100%
- MMU2 checkpointsClean100%
- PCI1 checkpointClean100%
- COP1 checkpointClean100%
- MOI1 checkpointClean100%
- PFE1 checkpointClean100%
Findings Raised During Trace (1)
- Dr. Lucas Dubois · Due 24 Oct 2026mediumEvidence gap identified for IPSG.2 during mock surveyor; requires documented remediation. (demonstration)
What you have recorded
18 of 18 points- ArrivalCompliant
Access and acceptance
Staff demonstrated the step without prompting and produced the record on request.
Emergency·5 of 10 records compliant·demonstrated·ACC·1 evidence artifact - ArrivalCompliant
Two-identifier verification
Practice at the bedside matched the written process; the record was complete and timed.
Emergency·4 of 10 records compliant·described·IPSG·1 evidence artifact - TriageCompliant
Acuity assignment and reassessment
Asked two members of staff independently; both described the same process and located the evidence.
Emergency·5 of 10 records compliant·demonstrated·AOPACC·1 evidence artifact - TriageCompliant
Falls risk screening
Staff demonstrated the step without prompting and produced the record on request.
Emergency·5 of 10 records compliant·demonstrated·IPSG·1 evidence artifact - Initial assessmentCompliant
Timeliness and qualification
Practice at the bedside matched the written process; the record was complete and timed.
Emergency·5 of 10 records compliant·described·AOPSQE·1 evidence artifact - Initial assessmentCompliant
Consent and privacy
Asked two members of staff independently; both described the same process and located the evidence.
Emergency·4 of 10 records compliant·described·PFR·1 evidence artifact - DiagnosticsPartial
Critical result communication
Process is understood and mostly followed, but the record is incomplete for part of the period reviewed.
Radiology·10 of 10 records compliant·demonstrated·IPSG·1 evidence artifact - DiagnosticsPartial
Imaging equipment status
Practice was correct where observed, though staff could not locate the governing document on the unit.
Radiology·7 of 10 records compliant·described·FMS·2 evidence artifacts - InterventionNon-compliant
Time-out and site verification
The evidence produced contradicts the written process for this unit.
Operating Theatres·4 of 10 records compliant·described·IPSGASC·1 evidence artifact - InterventionNot applicable
Anaesthesia assessment and monitoring
No patients meeting the criterion were present during the trace.
Operating Theatres·ASC·1 evidence artifact - Care unitCompliant
High-alert medication storage
Practice at the bedside matched the written process; the record was complete and timed.
ICU·4 of 10 records compliant·demonstrated·IPSGMMU·3 evidence artifacts - Care unitCompliant
Line care and hand hygiene
Asked two members of staff independently; both described the same process and located the evidence.
ICU·4 of 10 records compliant·demonstrated·PCI·2 evidence artifacts - HandoverCompliant
Structured handover
Staff demonstrated the step without prompting and produced the record on request.
ICU·9 of 10 records compliant·demonstrated·IPSGCOP·1 evidence artifact - HandoverCompliant
Medication reconciliation at transfer
Practice at the bedside matched the written process; the record was complete and timed.
ICU·10 of 10 records compliant·demonstrated·MMU·1 evidence artifact - DischargeCompliant
Discharge summary completeness
Asked two members of staff independently; both described the same process and located the evidence.
Outpatients·5 of 10 records compliant·demonstrated·ACCMOI·1 evidence artifact - DischargeCompliant
Patient and family education
Staff demonstrated the step without prompting and produced the record on request.
Outpatients·8 of 10 records compliant·demonstrated·PFE·1 evidence artifact - Follow-upPartial
Continuity of care
Practice was correct where observed, though staff could not locate the governing document on the unit.
Outpatients·9 of 10 records compliant·demonstrated·ACC·1 evidence artifact - Follow-upPartial
Outcome data capture
Two of the sample met the standard in full; the remainder were missing a timed signature.
Outpatients·7 of 10 records compliant·demonstrated·QPS·1 evidence artifact