Patient MG-4445, 73F — femoral neck fracture with delirium and falls risk
18 of 18 points observed
Individual patient tracer — acute medical admission · Ravi Shanmugam
Surveyor Tracer Final Report
Official Joint Commission International accreditation tracer summary
Patient MG-4445, 73F — femoral neck fracture with delirium and falls risk
Individual patient tracer — acute medical admission · Emergency
- Point Compliance
- 75%
- 16 checkpoints scored
- Findings Raised
- 0
- Actionable deficit citations
- Surveyor Sign-off
- Ravi Shanmugam
- Attested 2026-09-16
Chapter Compliance Telemetry
Standard adherence computed across all observed checkpoints for this trace
- SQE1 checkpoint1 gap0%
- MOI1 checkpoint1 gap0%
- AOP2 checkpoints1 gap25%
- COP1 checkpointClean50%
- ACC4 checkpoints1 gap63%
- MMU2 checkpointsClean75%
- IPSG6 checkpointsClean83%
- FMS1 checkpointClean100%
- ASC2 checkpointsClean100%
- PCI1 checkpointClean100%
- QPS1 checkpointClean100%
What you have recorded
18 of 18 points- ArrivalCompliant
Access and acceptance
Asked two members of staff independently; both described the same process and located the evidence.
Emergency·4 of 10 records compliant·described·ACC·1 evidence artifact - ArrivalCompliant
Two-identifier verification
Staff demonstrated the step without prompting and produced the record on request.
Emergency·6 of 10 records compliant·demonstrated·IPSG·1 evidence artifact - TriagePartial
Acuity assignment and reassessment
Practice was correct where observed, though staff could not locate the governing document on the unit.
Emergency·6 of 10 records compliant·described·AOPACC·1 evidence artifact - TriagePartial
Falls risk screening
Two of the sample met the standard in full; the remainder were missing a timed signature.
Emergency·10 of 10 records compliant·demonstrated·IPSG·1 evidence artifact - Initial assessmentNon-compliant
Timeliness and qualification
Neither the practice nor the record met the standard in the sample reviewed.
Emergency·8 of 10 records compliant·demonstrated·AOPSQE·1 evidence artifact - Initial assessmentNot applicable
Consent and privacy
No patients meeting the criterion were present during the trace.
Emergency·PFR·1 evidence artifact - DiagnosticsCompliant
Critical result communication
Asked two members of staff independently; both described the same process and located the evidence.
Radiology·8 of 10 records compliant·described·IPSG·1 evidence artifact - DiagnosticsCompliant
Imaging equipment status
Staff demonstrated the step without prompting and produced the record on request.
Radiology·5 of 10 records compliant·described·FMS·2 evidence artifacts - InterventionCompliant
Time-out and site verification
Practice at the bedside matched the written process; the record was complete and timed.
Operating Theatres·5 of 10 records compliant·demonstrated·IPSGASC·1 evidence artifact - InterventionCompliant
Anaesthesia assessment and monitoring
Asked two members of staff independently; both described the same process and located the evidence.
Operating Theatres·5 of 10 records compliant·demonstrated·ASC·1 evidence artifact - Care unitCompliant
High-alert medication storage
Staff demonstrated the step without prompting and produced the record on request.
ICU·4 of 10 records compliant·demonstrated·IPSGMMU·3 evidence artifacts - Care unitCompliant
Line care and hand hygiene
Practice at the bedside matched the written process; the record was complete and timed.
ICU·8 of 10 records compliant·demonstrated·PCI·2 evidence artifacts - HandoverPartial
Structured handover
Two of the sample met the standard in full; the remainder were missing a timed signature.
ICU·4 of 10 records compliant·demonstrated·IPSGCOP·1 evidence artifact - HandoverPartial
Medication reconciliation at transfer
Process is understood and mostly followed, but the record is incomplete for part of the period reviewed.
ICU·7 of 10 records compliant·demonstrated·MMU·1 evidence artifact - DischargeNon-compliant
Discharge summary completeness
Staff described the correct process but could not demonstrate it, and no record exists for the period.
Outpatients·4 of 10 records compliant·described·ACCMOI·1 evidence artifact - DischargeNot applicable
Patient and family education
No patients meeting the criterion were present during the trace.
Outpatients·PFE·1 evidence artifact - Follow-upCompliant
Continuity of care
Staff demonstrated the step without prompting and produced the record on request.
Outpatients·4 of 10 records compliant·demonstrated·ACC·1 evidence artifact - Follow-upCompliant
Outcome data capture
Practice at the bedside matched the written process; the record was complete and timed.
Outpatients·8 of 10 records compliant·described·QPS·1 evidence artifact