Patient MG-4423, 48M — acute NSTEMI transferred from district clinic
18 of 18 points observed
Individual patient tracer — acute medical admission · Dr. Tomas Lindqvist
Surveyor Tracer Final Report
Official Joint Commission International accreditation tracer summary
Patient MG-4423, 48M — acute NSTEMI transferred from district clinic
Individual patient tracer — acute medical admission · ICU
- Point Compliance
- 78%
- 16 checkpoints scored
- Findings Raised
- 1
- Actionable deficit citations
- Surveyor Sign-off
- Dr. Tomas Lindqvist
- Attested 2026-09-15
Chapter Compliance Telemetry
Standard adherence computed across all observed checkpoints for this trace
- PCI1 checkpoint1 gap0%
- IPSG5 checkpoints1 gap70%
- ASC2 checkpointsClean75%
- MMU2 checkpointsClean75%
- ACC3 checkpointsClean83%
- AOP1 checkpointClean100%
- SQE1 checkpointClean100%
- PFR1 checkpointClean100%
- FMS1 checkpointClean100%
- MOI1 checkpointClean100%
- PFE1 checkpointClean100%
- QPS1 checkpointClean100%
Findings Raised During Trace (1)
- Dr. Lucas Dubois · Due 26 Sep 2026mediumEvidence gap identified for PCI.5 during mock surveyor; requires documented remediation. (demonstration)
What you have recorded
18 of 18 points- ArrivalPartial
Access and acceptance
Practice was correct where observed, though staff could not locate the governing document on the unit.
Emergency·9 of 10 records compliant·demonstrated·ACC·1 evidence artifact - ArrivalNon-compliant
Two-identifier verification
The evidence produced contradicts the written process for this unit.
Emergency·8 of 10 records compliant·described·IPSG·1 evidence artifact - TriageNot applicable
Acuity assignment and reassessment
No patients meeting the criterion were present during the trace.
Emergency·AOPACC·1 evidence artifact - TriageCompliant
Falls risk screening
Practice at the bedside matched the written process; the record was complete and timed.
Emergency·8 of 10 records compliant·demonstrated·IPSG·1 evidence artifact - Initial assessmentCompliant
Timeliness and qualification
Asked two members of staff independently; both described the same process and located the evidence.
Emergency·8 of 10 records compliant·demonstrated·AOPSQE·1 evidence artifact - Initial assessmentCompliant
Consent and privacy
Staff demonstrated the step without prompting and produced the record on request.
Emergency·5 of 10 records compliant·demonstrated·PFR·1 evidence artifact - DiagnosticsCompliant
Critical result communication
Practice at the bedside matched the written process; the record was complete and timed.
Radiology·5 of 10 records compliant·demonstrated·IPSG·1 evidence artifact - DiagnosticsCompliant
Imaging equipment status
Asked two members of staff independently; both described the same process and located the evidence.
Radiology·9 of 10 records compliant·described·FMS·2 evidence artifacts - InterventionCompliant
Time-out and site verification
Staff demonstrated the step without prompting and produced the record on request.
Operating Theatres·9 of 10 records compliant·demonstrated·IPSGASC·1 evidence artifact - InterventionPartial
Anaesthesia assessment and monitoring
Practice was correct where observed, though staff could not locate the governing document on the unit.
Operating Theatres·7 of 10 records compliant·demonstrated·ASC·1 evidence artifact - Care unitPartial
High-alert medication storage
Two of the sample met the standard in full; the remainder were missing a timed signature.
ICU·7 of 10 records compliant·demonstrated·IPSGMMU·3 evidence artifacts - Care unitNon-compliant
Line care and hand hygiene
Neither the practice nor the record met the standard in the sample reviewed.
ICU·4 of 10 records compliant·described·PCI·2 evidence artifacts - HandoverNot applicable
Structured handover
No patients meeting the criterion were present during the trace.
ICU·IPSGCOP·1 evidence artifact - HandoverCompliant
Medication reconciliation at transfer
Asked two members of staff independently; both described the same process and located the evidence.
ICU·8 of 10 records compliant·demonstrated·MMU·1 evidence artifact - DischargeCompliant
Discharge summary completeness
Staff demonstrated the step without prompting and produced the record on request.
Outpatients·5 of 10 records compliant·demonstrated·ACCMOI·1 evidence artifact - DischargeCompliant
Patient and family education
Practice at the bedside matched the written process; the record was complete and timed.
Outpatients·10 of 10 records compliant·demonstrated·PFE·1 evidence artifact - Follow-upCompliant
Continuity of care
Asked two members of staff independently; both described the same process and located the evidence.
Outpatients·10 of 10 records compliant·demonstrated·ACC·1 evidence artifact - Follow-upCompliant
Outcome data capture
Staff demonstrated the step without prompting and produced the record on request.
Outpatients·6 of 10 records compliant·demonstrated·QPS·1 evidence artifact