Insufficient Documentation

NFPA 25 and NFPA 72 have requirements for what information should be included on documentation for inspection and testing fire alarm and sprinkler system components. The Joint Commission states clearly items that must be on the documentation. This chart shows top reasons for Joint Commission findings related to insufficient documentation.

Insufficient Documentation Graph

Mitigation tools:

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The hospital manages risks associated with its utility systems.
(August/September 2015)

The hospital maintains the integrity of the means of egress.
(October/November 2015)

The hospital establishes and maintains a safe, functional environment.
(December/January 2016)

The hospital maintains fire safety equipment and fire safety building features.
(February/March 2016)

Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
(April/May 2016)

The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
(June/July 2016)

The hospital provides and maintains equipment for extinguishing fires.
(August/September 2016)

The hospital manages risks related to hazardous materials and waste.
(October/November 2016)

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