The Joint Commission

The Joint Commission is an independent, not-for-profit organization that accredits, certifies and manages health care organizations in the United States. Like other accreditation organizations, the Joint Commission also promotes effective, continuous improvements of quality and safety within health care organizations and national public health organizations.

The Joint Commission website

Tracer Methodology

The surveyor will trace or follow current patients through the hospital by looking at their medical record from admission to current location. The patient is referred to as the "tracer." Surveyors will interview the actual caregivers. They will compare verbal accounts and observations against what is actually documented in the medical record and against hospital/department policy.

Effective July 2016, TJC has eliminated 319 elements of performance of the nearly 1,700 standards and elements of performance. Again, TJC is now aligned with the CMS regulations.

  • Contact your TJC facility/organization Representative who handles TJC standards for current manual accreditation updates.

The following standards and element of performance within the Chapter – Provision of Care, Treatment, and Services need to be reviewed as these pertain to the functions of the RDNs and NDTRs.

Provision of Care, Treatment, and Services (PC)

  • Plan
    • Admission to the Organization
    • Assessment (Screening)
      • PC01.02.01 EoP 1, 2, 3
      • PC.01.02.03 EoP 1, 2, 3, 6
    • Planning Care
  • Implement
    • Providing Care
      • PC.02.01.01 EoP 1
      • PC.02.01.03
      • PC.02.01.05 EoP 1
      • PC.02.01.21
    • Coordinating Care
      • PC.02.02.01 EoP 1, 2, 3, 17
      • PC.02.02.03
    • Patient Education
      • PC.02.03.01 EoP 1, 5, 10, 25, 27 (Note- EoP 10: bullet on nutrition interventions and modified diets)
    • Primary Care Medicare Home

Note the standards and element of performance within the Chapter – Record of Care, Treatment, and Services especially RC.02.01.01 and EoP 2 and RC.02.04.01 EoP.