AFT2 – Task 3
Western Governors University
Table of Contents
Evaluation 3
Plan 4
References 5
Evaluation
After review of the tracer patient information an outstanding patient care issue was
identified. The second item on Nightingale’s Surgical Patient Tracer Worksheet regarding the
patient’s history and physical is out of compliance. No documentation of a history and physical
within 24 hours of admission was found; this includes a physician admission assessment nor
initial nursing assessment. . Documentation on the tracer worksheet states that the history and
physical was not performed for greater than 72 hours after admission. This is a violation of Joint
Commission standard PC.01.02.03. According to the Joint Commission (2021), a nursing
assessment performed by a registered nurse must be completed and documented in the patient’s
chart within 24 hours of admission. An admission history and physical is a crucially important
element of care that is instrumental in determining appropriateness of future healthcare decisions
that will be made throughout the patient’s admission. In the absence of the admission history and
physical the patient care team may miss picking up on current and historical clinically
significant information about the patient, current or recently discontinued medications, and/or
allergies that the patient may have. Missing any one of these elements, or a combination of them,
