CCNA Quality - EPIC Documentation Audit Tool

• Site conducted

  Select GICU ACVICU NCCU ICUD PICU-CSH PICU-MH NICU 3 NICU 2 PCVICU

  • GICU
  • ACVICU
  • NCCU
  • ICUD
  • PICU-CSH
  • PICU-MH
  • NICU 3
  • NICU 2
  • PCVICU

• Conducted on

  Date

• Prepared by

• Patient's MRN

Name of Nurse

• undefined

CRITERIA

Documentation

• All patients shall be assessed upon admission and reassessed based on patient condition and documented in EMR

  Compliant

  Non-Compliant

  N/A

• Initial pain screening upon admission, every 4 hours and if changes in patient’s condition

  Compliant

  Non-Compliant

  N/A

• Nursing assessments are completed and documented for all patients prior to surgery, anesthesia or invasive procedures

  Compliant

  Non-Compliant

  N/A

• 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

  Compliant

  Non-Compliant

  N/A

• All collected assessment data must be integrated by the Multidisciplinary Care Team and utilized to identify and prioritize patient care needs

  Compliant

  Non-Compliant

  N/A

• Health care providers shall document in EPIC system tools for fall assessment. eg (Humpty Dumpty)

  Compliant

  Non-Compliant

  N/A

• Health care providers shall document in EPIC system tools for VTE assessment.

  Compliant

  Non-Compliant

  N/A

A

• Used of appropriate KFMC approved pain assessment tool (Wong baker, Visual Numeric, CRIES, FLACC, PIPP, COPT)

  Compliant

  Non-Compliant

  N/A

• Show me orders for Restraints, all monitoring and care documented in the patient EMR hourly, orders renewed every 24 hours

  Compliant

  Non-Compliant

  N/A

• Pressure injury risk assessment should be conducted for all patients using the age appropriate Braden scale Pressure Injury Risk Assessment

  Compliant

  Non-Compliant

  N/A

• 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.

  Compliant

  Non-Compliant

  N/A

• Central line, peripheral line assessment, documentation done (30 minutes, hourly, hours) as per policy

  Compliant

  Non-Compliant

  N/A

• The expected length of stay_ELOS_ has been documented in the patient's EMR

  Compliant

  Non-Compliant

  N/A

• Discharge Planning/Goals Identified and updated

  Compliant

  Non-Compliant

  N/A

• Nursing Handover at the end of the shift/transfer of care is complete according to "ISBAR"

  Compliant

  Non-Compliant

  N/A

KNOWLEDGE ASSESSMENT

• The nurse is able to verbalize the meaning of Line Reconciliation: it is a tactile and visual process that requires placing the hand on each infusion and physically tracing the line from the patient to the source

  Yes

  No

  N/A

• The nurse is able to verbalize the difference between General consent(routine predefined procedures and treatment 1st encountered at KFMC , and informed consent( voluntary permission to perform a procedure treatment after privileged health care worker gave adequate information)

  Yes

  No

  N/A

• The nurse is able to verbalize the KFMC policy related to Restraints

  Yes

  No

  N/A

Reference: CPP143282 ASSESSMENT, REASSESSMENT AND CARE PLAN OF PATIENTS, CPP 1431371, Admission Process in KFMC, CPP 1431398, Pain Assessment & Management, CPP 143703, Religious and Spiritual Counselling Care Provision, CMG No. 11255013137 PREVENTION OF CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION, 112110142 TITLE: ARTERIAL LINE INSERTION AND THE MANAGEMENT OF COMPLICATIONS, CPP 1431105 informed consent