Winning Habits Four core practices to keep your ASC on top of patient satisfaction BY NANCY JO VINSON, RN, CASC

As an Accreditation Asso- ciation for Ambulatory Health Care (AAAHC) sur- veyor for ambulatory set- tings, I often see consistency

in areas where ambulatory organizations excel and where they struggle when seek- ing accreditation. Based on that experi- ence and feedback from my colleagues, I suggest the following four core daily hab- its that will help an ASC maintain a high level of patient care and satisfaction.

1. Document a patient visit the same day it occurs to help ensure that all information is recorded accurately. Accurately documenting a patient visit is the most important task you will accomplish in a day aside from inter- acting directly with the patient. Be sure to include all relevant details of the encounter in a consistent manner so information is easily found and cor- rectly interpreted by your colleagues. Ideally, all providers should aim for clinical records that are complete, comprehensive, legible and accurate and provide easy access to informa- tion to support high quality care for each patient.

2. Always ask patients about their allergies and record the presence of allergies and untoward reactions to drugs in a prominent and consistent location in all clinical records. Up-to-date, accurate information about patient allergies and untoward reac- tions is critical to providing high qual- ity, safe patient care, and it is vital that all clinical records contain this infor- mation. However, the AAAHC Insti- tute for Quality Improvement’s 2014 Accreditation Association Electronic


National Evaluation and Information Dataset (AENEID) report indicated that more than 20 percent of surveyed organizations received a rating of par- tially or non-compliant from AAAHC surveyors evaluating this standard. During accreditation surveys, orga- nizations might struggle to meet this requirement if allergies have not been verified and updated on each visit; documentation regarding allergies is inconsistently located in clinical records; “allergies” are listed, but the

reactions are not; or there is reliance on “NKDA” (no known drug aller- gies) without reference to other types of allergies or sensitivities.

The presence or absence of aller- gies and untoward reactions to drugs and materials should be recorded in a prominent and consistently defined location in all clinical records. This information should be verified at each patient encounter and updated when- ever new allergies or sensitivities are identified. Be sure to enter “unknown”

The advice and opinions expressed in this article are those of the author’s and do not represent official Ambulatory Surgery Center Association policy or opinion.

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