Audit

MR# of charts reviewed:

DOCUMENTATION (PRE-OP PROVIDER)
RECORD OF CARE

Verbal orders are co-signed by the end of the next calender day

H&P

H&P completed no more than 30 days before or 24 hours after patient admission

H&P UPDATE NOTE

H&P update note by JHH provider within 24 hours after admission and before surgery

PROCEDURAL INFORMED CONSENT

Procedure informed consent completed, signed, witnessed, dated and timed before any procedure

Procedural informed consent clearly documents the risks and benefits of the alternatives to the surgery?

TIME-OUT FOR BEDSIDE PROCEDURE(S)

Time is documented
Correct patient identity
Correct site
Procedure to be done

PRE-ANESTHESIA ASSESSMENT

Pre-anesthesia assessment documentation contains the following elements completed prior to the induction of anesthesia or moderate/deep sedation:
Heart
Lung
Airway
ASA classificaton
Review of lmedical history, including anesthesia, drug and allergy history
Plan for anesthesia care

ANESTHESIA INFORMED CONSENT

Anesthesia informed consent completed, signed, witnessed, dated and timed before procedure(s)

POST-ANESTHESIA EVAL

Is post-anesthesia evaluation documentation present within 48 hours of the procedure?

Required elements are documented no more than 48 hours post-procedure:
Respiratory function (respiratory rate, airway patency, oxygen saturation)
Cardiovascular function (pulse rate and blood pressure)
Mental status
Temperature
Pain
Nausea and vomiting
Postoperative hydration

IMMEDIATE POST-OP NOTE/ BRIEF OP NOTE

Is the immediate post-op note/ brief op note present immediatlely afer procedure and before transfer to PACU or sending unit?

Required elements documeted immediately after procedure and before transfer to PACU or sending unit:
Surgeon and assistant names
Procedure performed
Description of findings
Post-op diagnosis
Estimated blood loss
Specimens removed

DETAILED POST-OP NOTE

Is the detailed op-note present and finalized wihtin 7 days of post-procedure?

Required elements documented within 7 days post-procedure
All elements specified from immediate post-op note PLUS:
Detailed description of procedure
Clinical stage of tumor as appropriate

RESTRAINTS
RESTRAINT ORDERS: VIOLENT

Violent/Self-Destructive patient orders every:
4 hours for adults > 18 yrs
2 hours for children 9-17 yrs
1 hour for children < 9 yrs

Violent/Self Destructive Patient Evalutation
In-person face-to-face evaluation within 1 hour of initiation of restraints/seclusion and 24 hours thereafter
Evaluation of patient's immediate situation
Patient's reaction to the intervention
Patient's medical and behavioral condition
Need to continue or terminate restraint/seclusiion

RESTRAINT ORDERS: NON-VIOLENT

Non-Violent Patient Orders: Initiation order obtained within 24 hours

Non-Violent Patient Order: Recurring order obtained by the end of each calender day

DOCUMENTATION

Nursing documentation reflects appropriate documentation:
Non-Violent- Q2 hours
Violent/ Self Destructive- Q 15 minutes

NURSING (NON-PROCEDURAL) DOCUMENTATION
PLAN OF CARE

Nursing Plane of Care documented and updated per patient's diagnosis and current condition (review 3 days of documentation, starting on day two of admission).

Progress Toward Outcome Note documented daily

Evidence of interdisciplinary care documented in chart

ADMISSION SCREEN

Admission Screening Note completed in POE within 24 hours of admisssion

MED REC

Home Medication List completed in POE within 24 hours

FALL PROTOCOL

Fall risk assessment done q day (review 72 hours of charting)

Appropriate communication that the patient is on Fall Precautions (flag at bedside for moderate/high risk)

PATIENT EDUCATION

Patient education appropriate to patient's condition is documented in POE

PAIN ASSESMENT

Routine pain assessment: Staff performs assessment based on pain scale used and last score. *Minimum of every 12 hours*

PCA pain medication: Staff performs assessments oa minimum of every 4 hours when on a stable dose, and q2 x2 after a dose change or bolus

PRN dose of pain medication: Assessment documented prior to administration of prn medications.

PRN dose of pain medication: Reassessment documented within 4 hours post prn medication administration

ADVANCE DIRECTIVES (AD)

AD form is completed (Responsibility of Registration Staff- paper)

Nurse Admisssion Screening Note indicates AD status

No discrepancies between AD Notification Form and Nurse Admisssion Screening

If patient has AD, copy of AD is chart or patient completed Patient Wishes Form.

MEDICATION OREDERS

Medications ordered as titrate have orders for:
Initial starting rate
Parameters for titration

If PRN medications are ordered for the same indication (e.g., nausea or pain medications) there are clear instructions on which drug would be used first

VAD CHECKLIST

If patient had a central line inserted, Is there a completed Central Line Checklist (paper form) in th Medical Record?

OBSERVATION/INTERVIEW
PATIENT ID

No work-a-rounds for barcode devices is evident

REDUCE RISK OF INFECTIONS

Staff can verbalize how they know unit equpment is clean and ready o use

Staff can verbalize appropriate contact times for low level cleaning and disinfection
Routine
Isolation

Is isolation status documented on Treatment and Cares flowsheet in POE?

MEDICAL EQUIPMENT

Glucometer supplies are dated with open and expiration dates

MEDICATION SAFETY (Bedside Procedures/ Storage)

Insulin pens are labeld with patient name. Staff can verbalize single patient use only for insulin pens due to risk of blood borne pathogen exposure.

Med carts/rooms are locked, no unsecured medicaions found on unit (check pneumatic tube areas, emergency drug boxes, crash carts, patient care rooms for insulin pens, anesthesia carts if no staff in the room)

Multi-dose vials are labeled with 28 day expiration date and initials

No Multi-dose vials present in patient care areas

OTHER

Emergency Equipment checklist has daily documentation for all days open

Only current months checklist available out on the unit (older forms should be stored in office so available upon request)

Eye wash logs present and completed weekly

Patient Food and drink appropriately labeled and not expired

Stored oxygen is separated into full (green rack) and empty( red rack) storage

Laryngoscope blades are stored appropriately

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.