CCNA Quality - EPIC Documentation Audit Tool

Title Page

Open File -EMR- Audit

CRITERIA

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.

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"