Title Page
-
Site conducted- EMR
- GICU
- ACVICU
- NCCU
- ICUD
- PICU-CSH
- PICU-MH
- NICU 3
- NICU 2
- PCVICU
-
Conducted on
-
Prepared by
-
Patient's MRN
Open File -EMR- Audit
CRITERIA
Documentation
-
All patients shall be assessed upon admission and reassessed based on patient condition and documented in EMR
-
Initial pain screening upon admission, every 4 hours and if changes in patient’s condition
-
Nursing assessments are completed and documented for all patients prior to surgery, anesthesia or invasive procedures
-
Patients and families shall be assessed for their educational needs and are involved in the planning of education. Their readiness to learn and barriers to learning will be assessed on admission
-
All collected assessment data must be integrated by the Multidisciplinary Care Team and utilized to identify and prioritize patient care needs
-
Health care providers shall document in EPIC system tools for fall assessment. eg (Humpty Dumpty)
-
Health care providers shall document in EPIC system tools for VTE assessment.
A
-
Used of appropriate KFMC approved pain assessment tool (Wong baker, Visual Numeric, CRIES, FLACC, PIPP, COPT)
-
Show me orders for Restraints, all monitoring and care documented in the patient EMR hourly, orders renewed every 24 hours
-
Pressure injury risk assessment should be conducted for all patients using the age appropriate Braden scale Pressure Injury Risk Assessment
-
The central line documentation in the flowsheets, date and site of insertion, when the due dressing and necessity of the central line has been discussed with the medical team.
-
Central line, peripheral line assessment, documentation done (30 minutes, hourly, hours) as per policy
-
The expected length of stay_ELOS_ has been documented in the patient's EMR
-
Discharge Planning/Goals Identified and updated
-
Nursing Handover at the end of the shift/transfer of care is complete according to "ISBAR"
