Title Page
-
Site conducted
-
Conducted on
-
Prepared by
-
Location
-
Documented Nurse
-
MRN
-
Length in ED
ED Assessment and Documentation Audit
Nursing Documentation
-
Patient identification Verified
-
Ordered medication: Acknowledge and carried out
-
IV Medication associated to Alaris pump
-
Dual signatures performed before procedure
-
John Depency tools documented accurately per shift or any changes of patient condition
-
Patient's physical assessment done accurately
-
All stat ordered carried out accordingly
-
Intake and output chart documented accurately
-
Critical result escalated and documented accurately
-
Procedural consent secured for each procedures
MEASURABLE GOALS/ NURSING CARE PLAN
-
All sections of NCP appropriately completed
-
Patient assessed/ Reassessed
-
Nursing Diagnosis according to NANDAi
-
Measurable Goals are SMART
-
Goals in line with the nursing diagnosis
-
Proof of carrying out of planned care
-
There is evaluation of measurable goal
-
Age specific assessment completed
-
Psychosocial assessment completed
FALL RISK SCREENING
-
Use of appropriate and complete assessment tool. Ensure correct total score and interventions are ticked
-
All patients are assessed for risk of falling on admission, transfer, following a change in condition and/or post fall
-
Reassessment of falls should be done as per guidelines stipulated in the tool
-
A plan of care including fall prevention and precautions is to be implemented. Ensure preventive actions and interventions are ticked
-
Provide education on Standard Falls Precaution upon admission and as indicated
-
Post Fall Management: Recording fall in notes, completing a Datix report
PAIN ASSESSMENT, REASSESSMENT AND MANAGEMENT
-
Initial pain screening upon admission
-
Pain screening at specified interval (ex. Postoperative), vital signs or change of condition
-
Use of appropriate KFMC approved pain assessment tool (Wong Baker, Visual Numeric, CRIES, FLACC, MCPOT)
-
Complete pain assessment and reassessment for patients in pain
-
Provide assessment and management education upon admission and as indicated
NUTRITIONAL SCREENING
-
Patient is screened by nurse within 24 hours upon admission using the approved nutritional screening form
-
Patient's risk category ticked
-
Relevant patient risk factors ticked
-
Patient's height and weight recorded
-
Patient at risk referred and seen within 24 to 72 hours name of dietician informed, date and time of referral
-
Patients not at risk is referred within 7 days of admission (date of referral written)
PATIENT AND FAMILY EDUCATION
-
Patient's educational abilities and barriers are assessed and documented
-
Patient or family educational needs are assessed and documented
-
Patients and families are educated about: Participation in Care Plan
-
Patients and families are educated about: Infection control practices and personal hygiene
-
Patients and families are educated about: Required treatments and procedures
-
Patients and families are educated about: Use of Medical Equipment or appliances
-
Patients and families are educated about: Necessary medications, the frequency, potential sideeffects and fooddrug interactions
-
Patients and families are educated about: Rationale and benefits of any dietary restrictions
-
Patients and families are educated about: Pressure ulcer prevention
-
Patient educated using appropriate tools or methods
-
Evaluation of patient/ family's response to education (action plan generated if understanding unsatisfactorily)
-
Completeness of the form
LDA AND WOUND DOCUMENTATION
-
All related lines are documented
-
Assessment for line related documentation are documented accurately
-
Wounds are documented accurately
SKIN ASSESSMENT
-
Skin assessment documented accurately for initial assessment
-
Intervention done to prevent pressure injury
POCT
-
POCT Blood glucose documented as per workflow
-
POCT Urine Analysis documented as per workflow
-
POCT Urine pregnancy test documented as per workflow
-
POCT RSV documented as per workflow
OTHER DOCUMENTATIONS
-
All communication between providers documented in the provider notification
-
Nurse In charge review the documentation every 12 hour of shift or more
-
Endorsement between shift documented and receiving with acknowledgement
-
Endorsement during shift documented and receiving with acknowledgement by the 2nd nurse
