Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Patient information
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Patient's MRN:
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Patient location:
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Name of staff interviewed:
Admission Documentation
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When was the patient admitted?
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Is the patient's preferred language for discussing health care documented?
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Staff are able to verbalize process for locating a patient's Advanced Directive and where that information is documented.
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Is the H&P current (completed within 30 days prior to admission or 24 hours after admission) and complete (contains all required elements including chief complaint/HPI, PMH, ROS, meds, allergies, detailed exam of relevant systems, review of lab/ diagnostics, diagnosis, and plan of care)?
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What are the patient's allergies and where are they listed?
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Are all required nursing screenings completed within 24 hours after admission?
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Selection indicates screening WAS completed within 24 hours of admission:
- nutrition
- functional status
- abuse/neglect
- falls
- depression/suicide
- skin breakdown
- education
- social
- spiritual
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Was the initial assessment completed per policy?
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Has medication reconciliation been done for this patient? (Documented in Reconcile Meds Routine)
Plan of Care
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Can RN identify top two to three problems that are keeping this patient in the hospital?
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Are the top problems identified by the RN reflected in the POC?
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Are the goals set in the POC measurable?
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Is progress toward outcomes documented daily?
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Is the POC interdisciplinary?
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Is there evidence of patient and/or family involvement?
Patient Education
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Has patient education been documented on this patient?
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Is readiness of the patient/ family to learn documented?
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If patient is on isolation precautions then there is documented patient and family education regarding infection prevention related to isolation.
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Is there evidence that education is specific to the patient and ongoing?
Restraints
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Is the patient in restraints?
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- non-violent/ non-self-destructive behavior
- violent/ self-destructive behavior
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Is the order for restraints placed within 24 hours of initiation?
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Does the documented type of restraint match the order?
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Are neurovascular and skin integrity assessments and need for continued restraint documented every 2 hours?
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If continued use of the restraint is indicated, is the restraint order renewed by the end of the each calendar day?
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Is there documented patient/ family education about the use of restraints?
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Are restraints included in the plan of care for the patient?
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Was the restraint order placed immediately (or within minutes) of restraint application? (This may be an emergency phone or verbal order if the prescriber is not immediately available)
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If the prescriber is not present to evaluate the need for and order restraints upon initiation, is there documentation of a face to face evaluation of the patient by the prescriber within one hour of restraint initiation?
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Does the type of restraint documented match the order?
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If the patient is in 4 limb or all limb and torso restraints, is there continuous 1:1 observation provided by a trained care giver?
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Are observations of the patient documented every 15 minutes?
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Is there documentation at least every 2 hours that food, fluid, and toileting has been offered and ROM performed?
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Is there documentation by the RN of neurovascular and skin integrity assessments at least every 2 hours (while awake)?
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If not contraindicated by circumstances assessed by physician or RN, is hourly personal contact being documented for the purposes of assessing for special needs of the patient?
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What is the patient's age?
- less than 9
- 9-17
- 18 +
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Is the need for restraints re-evaluated and the order renewed hourly?
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Is the need for restraints re-evaluated and the order renewed every 2 hours?
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Is the need for restraints re-evaluated and the order renewed every 4 hours?
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If after release from restraint there is clinical justification to reapply restraints a new assessment is completed and new restraint order is obtained.
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Was the plan of care modified to include restraints and goals for discontinuation?
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Is there documented patient/ family education about the use of restraints?
Procedures
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Has the patient had any procedures?
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Is there an H&P Update Note completed within 24 hours prior to invasive procedure?
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Is informed consent present for the procedure?
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Are all the following elements present and complete on the consent? (Selection indicates elements are present)
- provider signature/date and time are present
- witness signature, date and time is present
- patient/ representative signature, date and time is present
- consent clearly documents risks and benefits of alternatives to the procedure
- the name of the procedure is documented on all pages of the consent.
- each individual signing the consent dates and times for him/herself
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Is anesthesia informed consent present in the chart?
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Are all the following elements present and complete on the anesthesia consent? (Selection indicates the element is present.)
- anesthesia consent is signed, dated and timed by anesthesiologist or CRNA
- witness signature, date and time are present.
- patient/ representative signature, date and time are present
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Is the pre-anesthesia assessment documented within 48 hours prior to procedure?
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Does the pre-anesthesia assessment contain all required elements? (Selection indicates element is present.)
- heart
- lungs
- airway
- ASA classification
- review of medical, anesthesia, drug and allergy history
- plan for anesthesia.
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Is time-out documented and complete?
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Time-out includes correct patient identification, correct site, correct procedure, date and time time out was completed.
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Is the post-anesthesia evaluation documentation present within 48 hours of the procedure?
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Are all required elements documented in post-anesthesia assessment? (Selection indicates element is present.)
- respiratory function
- temperature
- mental status
- assessment of nausea/ vomiting
- post-procedure hydration
- assessment of pain
- description of complication
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Is the immediate post-op note present immediately after procedure and before transfer to PACU or sending unit?
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Are all required elements included in the immediate post-op note? (selection indicates element is present.)
- surgeon and assistant names
- procedure performed
- pre-op diagnosis
- post-op diagnosis
- description of findings
- estimated blood loss (if applicable)
- specimens removed (if applicable)
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Is the detailed post-op note present and finalized within 7 days post-procedure?
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Are all required elements included in the detailed post-op note? (selection indicates element is present.h
- surgeon and assistant names
- procedure performed
- pre-op diagnosis
- post-op diagnosis
- description of findings
- EBL (if applicable)
- specimens removed (if applicable)
- detailed description of procedure
- clinical stage of tumor as appropriate
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If moderate sedation used, then vital signs including O2 saturation, HR, RR, BP and LOC are documented every 15 minutes until recovery criteria is met? ?
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If deep sedation used (ketamine, etomidate, or propofol), then vital signs including O2 saturation, HR, RR, BP and LOC are documented every 5 minutes until recovery criteria is met. (RNs may document during DSA, but do not have primary responsibility for monitoring the patient)?
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If the procedure requires continued frequent assessments or monitoring beyond recovery from sedation then documentation of assessments are per order or policy? (e.g. Frequent neurovascular assessments following interventional radiology procedure or reconstruction with flap for plastics procedure)
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Are staff able to locate the order set or policy that states frequency of procedure specific assessments?
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Staff are able to verbalize the clinical discharge criteria necessary to discontinue the Procedural Sedation Protocol.
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Clinical discharge criteria: Aldrete recovery score of 10 or patient baseline; return to baseline LOC; ability to swallow fluids/ secretions or demonstrate gag reflex; no evidence of severe hyper or hypotension; pulse is regular and within appropriate range for patient's age; respiratory rate and character are within range for patient's age, or oxygen saturation is >95% or at patient's baseline.
Medication orders
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If there are multiple PRN medications for the same indication (such as pain or nausea), are there clear instructions for when to use each medication? If there are examples of therapeutic duplication please list the medications and indications.
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What should the RN do if there are multiple PRN medications for the same indication with no instructions on what to give first? Answer: Get clarification from provider!
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If the patient received pain medication, then there is a documented pain reassessment within 1 hour of administration.
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The appropriate pain scale is used to assess the patient based on patient's developmental and cognitive state? (e.g. Numerical, FACES, Behavioral etc.)
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If a medication order has a dose range, does it specify starting dose and instructions for increasing the dose within the range?
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Does the administered dose match the instructions in the order? (e.g. oxycodone ordered for 5-10mg q4hr. 5mg to be given for mild pain and 10mg to be given for moderate or severe pain. Dose given is appropriate for pain score documented).
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If the patient has a titration order, does it include the starting dose, titration dose, frequency of titration, max dose and desired therapeutic effect.
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Documented starting dose matches ordered starting dose.
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Does titration documentation support titration to effect or to set parameters? (e.g. Versed gtt ordered to achieve RASS of 0 and therefore increases in versed gtt dose should have corresponding RASS documentation of >0).
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If the patient has a PCA order, it includes all of the following components: name and concentration of medication, dose, delay in minutes, basal rate, one-hour time limit, bolus, carrier fluid and monitoring parameters.
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The PCA order has an automatic 72hr stop date. (Prescriber order is required to extend the PCA order beyond 72 hours)
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Assessment of patient and monitoring of pump are performed and documented per policy.
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Ask RN to state the required documentation including frequency of assessments associated with PCA and compare to the chart. Request policy P050)
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If it is possible to observe medication administration, does the RN use 2 patient identifiers to validate correct patient?
Orders and Documentation
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If this patient has been ordered blood products, the order includes: component type, volume and flow rate. (NICU only: order also includes instructions to infuse via umbilical arterial or venous catheter).<br>
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A completed blood consent is present in the patient's chart.
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RN verbalizes patient verification process by two individuals. (Match patient name and history number from Blood I.D. band to the blood product. Check expiration date, ABO and Rh type on the requisition slip to those on the blood product. One individual must be MD or RN, the second witness may be an LPN).
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Are assessments documented per policy? (Have RN describe required assessment/ vital sign documentation. Per policy vital signs are required prior to blood administration, 15 mins after initiation of infusion, at 1 hour and then every hour during the transfusion)
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If the patient has been ordered routine weights, documentation of weights per order is present.
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If verbal orders are present in the EMR, they are complete and have been signed within 48 hours by the prescriber. (Have staff produce policy O010)
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If an oxygen order is present, the documentation of oxygen administration matches the order.
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RN states the process for receiving and reporting critical action values. (ICU, OR, ED, Procedure area, Care Center RNs may receive CAVs from the lab. Report of the CAV to the provider this documented in the medical record along with the CAV and date and time it was relayed.)
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Verbalizes hand-off process
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Has discharge planning been started for this patient?
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What evidence is documented that discharge planning is ongoing?
