Patient Rights

Citation

TJC HR.11.02.01

The hospital defines and verifies staff qualifications.

The standard addresses defining staff qualifications by job responsibility, including references to infection control, laboratory, rehabilitation, interpreter, and respiratory care qualifications.

Citation

TJC MM.16.01.01

The hospital safely administers medications.

The standard addresses medication administration under law, practitioner orders, standards of practice, medical staff policies, and patient or caregiver self-administration procedures.

Citation

TJC NPG.02.02.01

The hospital addresses conflicts of interest and ethics.

The standard requires hospital leaders to define, disclose, and manage conflicts of interest and to provide a process for staff, patients, and families to address ethical issues.

Citation

TJC NPG.03.02.02

The hospital has a communications plan that addresses how it will initiate and maintain commu...

The hospital must implement a communications plan to maintain contact with staff, patients, and community partners during emergency or disaster events.

Citation

TJC NPG.06.02.01

The hospital assesses and manages the patient’s pain and minimizes the risks associated with...

The hospital implements processes for screening, assessing, treating, and reassessing patient pain while managing risks associated with opioid treatment.

Citation

TJC NPG.07.01.01

The hospital respects the patient's right to receive information in a manner the patient unde...

Requires the hospital to respect the patient's right to effective communication and to provide interpreting, translation, and accommodation services for patients with language, vision, speech, hearing, or cognitive impairments.

Citation

TJC NPG.07.03.01

The hospital assesses the patient who may be a victim of possible abuse, neglect, and exploit...

Requires the hospital to identify, assess, report, and refer patients who may be victims of abuse, neglect, or exploitation, and to educate staff on recognition and follow-up.

Citation

TJC NPG.07.04.01

The hospital treats the patient in a dignified and respectful manner.

Requires the hospital to respect patients' cultural, personal, and spiritual values and to accommodate religious and spiritual services.

Citation

TJC NPG.12.05.01

The hospital provides education and training and evaluates staff competence.

Requires the hospital to orient staff, provide ongoing education, and evaluate staff competence at least every three years.

Citation

TJC NPG.14.05.01

The hospital maintains and communicates accurate patient medication information.

Requires the hospital to obtain, document, reconcile, and communicate accurate patient medication information across care transitions.

Citation

TJC PC.11.01.01

The hospital accepts the patient for care, treatment, and services based on its ability to me...

Requires the hospital to accept patients only when it can meet their needs and to implement a written admission process addressing criteria and referral procedures.

Citation

TJC PC.11.02.01

The hospital assesses and reassesses the patient and the patient's condition according to def...

Requires the hospital to assess and reassess patients within defined time frames, including initial assessments, medical history and physical examinations, and defined scope and content of screening.

Citation

TJC PC.11.02.03

The hospital assesses the needs of patients who receive treatment for emotional and behaviora...

Requires the hospital to assess the needs of patients receiving treatment for emotional and behavioral disorders, including psychiatric evaluation, psychological testing, and neurological examination when indicated.

Citation

TJC PC.11.02.05

The hospital assesses the needs of patients who receive psychosocial services to treat alcoho...

Requires the hospital to perform a comprehensive psychosocial assessment of patients receiving services for alcoholism or other substance use disorders.

Citation

TJC PC.11.02.07

The hospital assesses the patient’s communication needs.

Requires the hospital to identify each patient's oral and written communication needs, including preferred language and any needed aids or interpreters.

Citation

TJC PC.11.03.01

The hospital plans the patient’s care.

Requires the hospital to develop, implement, and revise an individualized written plan of care based on assessment findings and patient goals, with patient involvement.

Citation

TJC PC.12.02.01

The hospital provides patient education and training based on each patient’s needs and abilit...

Requires the hospital to assess learning needs, coordinate interdisciplinary education, deliver condition-specific teaching, and evaluate patient understanding.

Citation

TJC PC.13.01.03

The hospital provides the patient with care before and after operative or other high-risk pro...

Requires preanesthesia assessment, intraoperative and postanesthesia documentation, preprocedural education, immediate postoperative care, and qualified discharge.

Citation

TJC PC.14.01.01

The hospital follows its process for discharging or transferring patients.

Requires the hospital to operate an effective discharge and transfer planning process that begins early, involves the patient and care team, addresses post-acute needs, and is regularly assessed.

Citation

TJC RI.11.01.01

The hospital respects, protects, and promotes patient rights.

Requires the hospital to develop and implement written policies protecting patient rights, including safe care, non-discrimination, privacy, medical record access, and visitation rights.

Citation

TJC RI.11.02.01

The hospital respects the patient's right to receive information in a manner the patient unde...

Requires the hospital to provide information, including health status, in a manner tailored to the patient's age, language, and ability to understand.

Citation

TJC RI.12.01.01

The hospital respects the patient's right to participate in decisions about their care, treat...

Requires the hospital to respect and support the patient's right to participate in care decisions, including informed decisions, notification of admission, and advance directives.

Citation

TJC RI.12.02.01

The hospital respects the patient's right to receive information about the individual(s) resp...

Requires the hospital to inform the patient of the names of the licensed practitioners responsible for and providing the patient's care, treatment, and services.

Citation

TJC RI.13.01.01

The patient has the right to be free from harassment, neglect, exploitation, and verbal, ment...

Requires the hospital to protect patients from abuse, neglect, exploitation, and harassment, and to report allegations to appropriate authorities within specified time frames.

Citation

TJC RI.15.01.01

The hospital informs the patient about the patient's responsibilities related to their care,...

Requires the hospital to develop and implement a written policy defining patient responsibilities related to care, treatment, and services, and to inform patients of those responsibilities.