Records Requirements for Hospital Accreditation - HR Policy 410

Records Requirements for Hospital Accreditation - HR Policy 410

Abstract:
This policy identifies the requirements for the personnel records of UAB Hospital employees.
Effective Date:
6/1/2009
Responsible Party:
Contacts:
None Assigned
Administrative Category:
Applies To:
Staff
Material Original Source:

Policy 410 – Records Requirements for Hospital Accreditation

Date Issued: 10/80
Date Revised: 06/09

The Joint Commission on Accreditation of Healthcare Organizations has set requirements for the personnel records of UAB Hospital personnel. In order to meet the accreditation standards, the University personnel file of each active Hospital employee should include the following:

  1. Employment Application
  2. Job/Position Description
  3. Primary Source Verification of Licensure/Certification Required for Job
    1. Copy of licensure/certification, registration, or authorized verification document of Registered Nurse License
    2. Health-care provider - CPR (direct patient-care givers) including expiration date
    3. ACLS, TNCC, NRP, PALS (Registered Nurse only)
  4. Orientation/Initial Competency Assessment
    1. Hospital Orientation documentation
    2. Initial TB skin test from Employee Health
    3. Nursing Staff Dev. Competency/Testing Packet (Nursing)
    4. Nursing Staff Dev. Skills/Validation Booklet (Nursing)
    5. Competency Assessment/Skills Validation material (Non-nursing)
  5. Annual Competency/Performance Evaluations/Inservices
    1. Performance Appraisal
    2. Annual TB skin testing (from Employee Health)
    3. Periodic/Annual Competency Assessment/Skills Validation
    4. Test answer sheets (non-patient caregivers)
    5. Test answer sheets for annual mandatories
  6. Additional Job Specific Competency/Continuing Education
    1. Documentation of continuing education and additional skills classes/courses
    2. Documentation of classes necessary to implement/support Hospital initiated programs

Members of the JCAHO will review and inspect personnel files of employees selected during their review of hospital services. Hospital employees' personnel files are carefully monitored for all required information and departmental employee personnel files must be kept in an orderly manner and must be easily accessible for inspection.