Standard 1: Assessment, Care Planning and Safety (Version 11)

Why it matters. Too few nurses for the number of patients, or too few with the right skills, leads to missed care and avoidable harm. Staffing should be calculated from real demand, not from habit.

Sample. Take 5 shifts at random from the last month across the inpatient areas. For each shift, check the calculation, the rota and the gap record.

1. Staffing is calculated from patient volume and acuity.

Method. Check the calculation for each area for the last 4 weeks.

Evidence to show. Staffing calculation record (CLN-FRM-001).

Pass when. Every area has a calculation for each shift in the period.

2. Shifts run at or above the calculated level.

Method. Compare the rota with the calculation for each of the 5 shifts.

Evidence to show. Rota and calculation.

Pass when. At least 90% of the sampled shifts meet the calculated level.

3. Gaps are escalated.

Method. Check the gap record for each shift below the level.

Evidence to show. Gap record (CLN-FRM-001).

Pass when. Every gap has an action and an escalation recorded.

Immediate fail (any one means the criterion is not met)

• A shift runs below the calculated level with no escalation recorded.

Staff, training and documents

Each occupation carries its ISCO-08 code; see the Health Occupations Map. Each row is one document: read across to see who does each step. Click the document name for its full text.
Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

E-learning: who must take each course. Click a course for the explanation.

Documents: who does each step

Why it matters. A patient who is admitted without a structured assessment may have a problem missed until it is serious. A defined assessment on admission gives every patient the same thorough start.

Sample. Take 20 admissions from the last month, including 5 emergency admissions. Check each admission assessment for the defined process and the senior check.

1. Every patient has a structured assessment on admission.

Method. Check the admission assessment record for each of the 20 admissions.

Evidence to show. Admission assessment record (CLN-FRM-002).

Pass when. At least 90% of admissions have a complete structured assessment within the set time.

2. The assessment is done by a qualified clinician.

Method. Check the name and role of the assessor on each record.

Evidence to show. Admission assessment record.

Pass when. Every assessment names a qualified clinician.

3. Other disciplines are involved where the presentation requires it.

Method. Check the records where the presentation called for another discipline.

Evidence to show. Admission assessment record.

Pass when. Every case that required another discipline has their input recorded.

Immediate fail (any one means the criterion is not met)

• A patient is admitted with no structured assessment.

Staff, training and documents

Each row is one document: read across to see who does each step. Click the document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

E-learning: who must take each course. Click a course for the explanation.

Documents: who does each step

Reference drafts: adapt them to your hospital, replace them with your own, or upload your own.

Why it matters. A care plan that is generic does not fit the patient, and it guides nobody. An individual plan, built from the assessment and updated as the patient changes, is what makes treatment work.

Sample. Take 20 inpatients who have stayed more than 24 hours. Check each individual care plan for the assessment link, the goals and the patient involvement.

1. Each patient has an individual care plan.

Method. Check the care plan record for each of the 20 patients.

Evidence to show. Individual care plan (CLN-FRM-003).

Pass when. Every patient has a care plan by day 1.

2. The plan states goals and is built from the patient’s own assessment.

Method. Check each plan for goals and the link to the assessment.

Evidence to show. Individual care plan.

Pass when. At least 90% of plans have goals and a link to the assessment.

3. The patient, and family where appropriate, take part.

Method. Check for the patient’s view in each plan.

Evidence to show. Individual care plan.

Pass when. At least 90% of plans record the patient’s involvement.

Immediate fail (any one means the criterion is not met)

• A patient has no individual care plan after the first day of care.

Staff, training and documents

Each row is one document: read across to see who does each step. Click the document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

E-learning: who must take each course. Click a course for the explanation.

Documents: who does each step

Reference drafts: adapt them to your hospital, replace them with your own, or upload your own.

Why it matters. Restraint and seclusion can cause injury, distress and death, and they are often used for the convenience of staff. A protocol that treats them as a last resort, time-limited and monitored, protects the patient.

Sample. Review all restraint and seclusion records for the last 3 months, and the monthly review for each.

1. Each use follows the protocol and is ordered for a time limit.

Method. Check each record for the order and the time limit.

Evidence to show. Restraint and seclusion record (CLN-FRM-004).

Pass when. Every use has an order and a time limit.

2. A less restrictive option is recorded as tried first.

Method. Check each record for the less restrictive options.

Evidence to show. Restraint and seclusion record.

Pass when. Every use has the options recorded.

3. Each use is monitored and released when the risk passes.

Method. Check the monitoring checks and the release time.

Evidence to show. Restraint and seclusion record.

Pass when. Every use has monitoring checks and a release time.

Immediate fail (any one means the criterion is not met)

• Restraint or seclusion is used with no order, or continues past its time limit.

Staff, training and documents

Each row is one document: read across to see who does each step. Click the document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

E-learning: who must take each course. Click a course for the explanation.

Documents: who does each step

Reference drafts: adapt them to your hospital, replace them with your own, or upload your own.

Why it matters. Poor nutrition slows healing and raises the risk of complications. Screening patients for nutritional risk, and delivering the right diet, is a simple step that changes outcomes.

Sample. Take 20 inpatients from the last month. Check the nutrition screen, the diet on the order and the food safety record for 5 days.

1. Each patient is screened for nutritional risk on admission.

Method. Check the nutrition screen for each of the 20 patients.

Evidence to show. Nutrition risk screen record (CLN-FRM-005).

Pass when. At least 90% of patients have a screen on admission.

2. Therapeutic diets are delivered as ordered.

Method. Compare the diet on the order with the tray for each patient on the sample days.

Evidence to show. Diet order and tray record.

Pass when. At least 90% of therapeutic diets match the order.

3. Food handling meets basic safety standards.

Method. Check the food temperature and hygiene record on the sample days.

Evidence to show. Food safety record.

Pass when. Every sampled delivery has its temperature recorded and in range.

Immediate fail (any one means the criterion is not met)

• A patient at nutritional risk has no screen, or receives a diet different from the order.

Staff, training and documents

Each row is one document: read across to see who does each step. Click the document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

E-learning: who must take each course. Click a course for the explanation.

Documents: who does each step

Reference drafts: adapt them to your hospital, replace them with your own, or upload your own.

Additional materials

Guidelines, definitions and articles on news.gmj.ge that relate to this criterion.

Definitions

• Acute malnutrition in infants, children or adolescents · GMJ dictionary
  Acute malnutrition is a condition where the body lacks sufficient nutrients, leading to serious health issues. Children and adolescents only.

Why it matters. Pressure injuries develop in hours on a patient who cannot move, and they are among the most preventable harms in hospital. Assessing risk on admission and repeating it, with a plan, prevents them.

Sample. Take 20 patients from the last month, including 5 at risk. Check the admission assessment, the repositioning record and the skin checks.

1. Each patient is assessed for pressure injury risk on admission.

Method. Check the risk assessment for each of the 20 patients.

Evidence to show. Pressure injury risk record (CLN-FRM-006).

Pass when. At least 90% of patients have a risk assessment on admission.

2. Each at-risk patient has a written prevention plan.

Method. Check each at-risk patient for the repositioning schedule and surface.

Evidence to show. Pressure injury prevention record.

Pass when. Every at-risk patient has a plan.

3. Skin checks are done and changes are reported the same shift.

Method. Check the skin check record for the at-risk patients.

Evidence to show. Skin check record.

Pass when. At least 90% of skin checks are recorded, and every change is reported.

Immediate fail (any one means the criterion is not met)

• A pressure injury develops in an at-risk patient with no prevention plan in place.

Staff, training and documents

Each row is one document: read across to see who does each step. Click the document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

E-learning: who must take each course. Click a course for the explanation.

Documents: who does each step

Reference drafts: adapt them to your hospital, replace them with your own, or upload your own.

Why it matters. Blood clots in the legs that reach the lungs can kill a patient who looked well. Assessing every patient before admission and before surgery, and preventing clots in those at risk, is one of the most effective safety measures.

Sample. Take 20 admissions from the last month, including 10 surgical patients. Check the clot risk assessment and the prophylaxis record.

1. Each patient is assessed for clot risk on admission and before surgery.

Method. Check the assessment for each patient and each surgical procedure in the sample.

Evidence to show. VTE risk assessment record (CLN-FRM-007).

Pass when. At least 90% of assessments are done on admission and before surgery.

2. At-risk patients have prophylaxis prescribed.

Method. Check the prescription for each at-risk patient.

Evidence to show. Prescription and VTE record.

Pass when. Every at-risk patient has prophylaxis prescribed, or a reason recorded.

3. Prophylaxis is given as prescribed.

Method. Check the medicine administration record for each at-risk patient.

Evidence to show. Medicine administration record.

Pass when. At least 90% of prescribed doses are recorded as given.

Immediate fail (any one means the criterion is not met)

• An at-risk patient has no prophylaxis and no recorded reason.

Staff, training and documents

Each row is one document: read across to see who does each step. Click the document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

E-learning: who must take each course. Click a course for the explanation.

Documents: who does each step

Reference drafts: adapt them to your hospital, replace them with your own, or upload your own.

Additional materials

Guidelines, definitions and articles on news.gmj.ge that relate to this criterion.

Definitions

• Deep vein thrombosis · GMJ dictionary
  Deep vein thrombosis is a condition where blood clots form in deep veins, usually in the legs.