HealthLiteracyCopilot by HealthcareGPSFree kit · no form
Would your discharge medication sheet hold up in a tracer?
A standard-to-document crosswalk, a tracer worksheet, a document readiness check, an evidence log and a Goal 4 action-plan starter. All of it is on this page.
Last reviewed 2026-10-09
A preparation aid, not accreditation advice or evidence of compliance. Not affiliated with The Joint Commission, and not endorsed by it.
Surveys are unannounced
Since 2026-01-01, 14 National Performance Goals apply to the Hospital and Critical Access Hospital programs. A tracer follows one patient's real documents, and surveys come without notice. So readiness can't wait for a date.
Which documents a tracer can reach
The goals that touch patient documents, quoted from the public 2026 text, with the documents a surveyor may ask to see.
| Goal | What it says (abridged) | Documents a tracer can reach |
|---|---|---|
| NPG.07.01.01 EP 1–3 | "The hospital respects the patient's right to receive information in a manner the patient understands." EP 2: "provides interpreting and translation services, as necessary." EP 3: communicates with patients with vision, speech, hearing or cognitive impairments "in a manner that meets the patient's needs." | Patient rights notice, admission packet, and translated and accessible versions of every document below |
| NPG.07.02.01 EP 1 | A written informed-consent policy covering the care that requires consent, its risks, benefits and alternatives. | Consent forms and the plain-language explanations that go with them |
| NPG.14.05.01 EP 4–5 | "Written information on the medications the patient should be taking" at discharge or the end of an outpatient encounter (name, dose, route, frequency, purpose), and why managing that list matters. | Discharge medication list and medication education sheets |
| NPG.06.02.01 EP 8 | Educates the patient and family on discharge plans related to pain management: plan of care, side effects, and activities that might worsen pain. | Pain and opioid discharge instructions |
Tracer worksheet
Follow one patient's documents from admission to follow-up. Use a blank template of each document, never a patient's copy. The first row is an example.
| Stage | Document | Grade level | Languages | Accessible format | Owner | Version date |
|---|---|---|---|---|---|---|
| Discharge | Medication list (example) | 11 | English | No | None | [date] |
Type in the table, then download it for Excel or Google Sheets. Your entries stay in this tab: nothing is sent or saved, so download before you leave the page.
Evidence log
Record who reviewed which document, when, and against what standard. It is a record of review, not of compliance.
| Document | Version | Reviewer | Date | Standard | Result | Next review |
|---|---|---|---|---|---|---|
| Discharge medication list (example) | 2.1 | [name, role] | [date] | NPG.14.05.01 | Revised to grade 6, Spanish added | [date] |
Type in the table, then download it for Excel or Google Sheets. Your entries stay in this tab: nothing is sent or saved, so download before you leave the page.
Goal 4 action planning
NPG.04.01.01 asks the hospital to look at quality and safety data by groups such as preferred language, write an action plan for at least one gap it finds, act when it misses its goals, and report progress at least once a year. Its note allows measures that affect all patients, such as experience of care and communication. Your hospital chooses the gap, the measures and the goals. The worked example below uses communication by preferred language.
- Stratify: run your own aggregate data by preferred language, for example discharge-information or communication-about-medicines scores. Patient-level data stays inside your hospital.
- Write the plan: the gap, the goal, the actions, the owner and the dates.
- Pick an action. One option: measure and revise your 10 highest-volume discharge documents in Spanish, with Spanish readability measures.
- Track: the before and after measurements are process evidence the plan can cite.
- Report: share progress with leaders and staff at least once a year.
| Gap found | Goal | Action | Owner | Start | Progress check |
|---|---|---|---|---|---|
| Lower discharge-information scores for Spanish-preferring patients (example) | [goal] | Measure and revise the 10 highest-volume discharge documents in Spanish | [name, role] | [date] | [date] |
Type in the table, then download it for Excel or Google Sheets. Your entries stay in this tab: nothing is sent or saved, so download before you leave the page.
Document readiness check
Check each document a tracer can reach. Every "no" is a gap to review.
Complete this checklist: about 10 minutes
0 of 5 checked
Each document
Your answers stay in this tab: nothing is sent or saved. Download or print before you leave the page.
Sources
After the kit
Send a blank template, not a copy with a patient's or member's details.
Email me this resource
This resource is already open on this page. This sends you a link to it.
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Questions
Is this a Joint Commission compliance check?
No. It is a preparation aid. A review record is evidence of review, not of compliance, and it does not predict survey results.
Do you need patient data for Goal 4?
No. You run the stratification on your own aggregate data. We only see the documents you choose to send.