Inpatient Unit Tracer

• Conducted on

  Date

• Prepared by

• Service: MD:

• Document No.

• Location
  Address

• Staff Interviewed Name(s)/ Title:

• MR# of charts reviewed:

  Yes

  No

  N/A

DOCUMENTATION (PRE-OP PROVIDER)

RECORD OF CARE

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

  Yes

  No

  N/A

H&P

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

  Yes

  No

  N/A

H&P UPDATE NOTE

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

  Yes

  No

  N/A

PROCEDURAL INFORMED CONSENT

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

TIME-OUT FOR BEDSIDE PROCEDURE(S)

• Time is documented<br> Correct patient identity<br> Correct site<br> Procedure to be done

  Yes

  No

  N/A

PRE-ANESTHESIA ASSESSMENT

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

  Yes

  No

  N/A

ANESTHESIA INFORMED CONSENT

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

  Yes

  No

  N/A

POST-ANESTHESIA EVAL

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

DETAILED POST-OP NOTE

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

RESTRAINTS

RESTRAINT ORDERS: VIOLENT

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

RESTRAINT ORDERS: NON-VIOLENT

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

DOCUMENTATION

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

  Yes

  No

  N/A

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).

  Yes

  No

  N/A

• Progress Toward Outcome Note documented daily

  Yes

  No

  N/A

• Evidence of interdisciplinary care documented in chart

  Yes

  No

  N/A

ADMISSION SCREEN

• Admission Screening Note completed in POE within 24 hours of admisssion

  Yes

  No

  N/A

MED REC

• Home Medication List completed in POE within 24 hours

  Yes

  No

  N/A

FALL PROTOCOL

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

PATIENT EDUCATION

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

  Yes

  No

  N/A

PAIN ASSESMENT

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

ADVANCE DIRECTIVES (AD)

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

  Yes

  No

  N/A

• Nurse Admisssion Screening Note indicates AD status

  Yes

  No

  N/A

• No discrepancies between AD Notification Form and Nurse Admisssion Screening

  Yes

  No

  N/A

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

  Yes

  No

  N/A

MEDICATION OREDERS

• Medications ordered as titrate have orders for:<br> Initial starting rate<br> Parameters for titration

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

VAD CHECKLIST

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

  Yes

  No

  N/A

OBSERVATION/INTERVIEW

PATIENT ID

• No work-a-rounds for barcode devices is evident

  Yes

  No

  N/A

REDUCE RISK OF INFECTIONS

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

  Yes

  No

  N/A

• Staff can verbalize appropriate contact times for low level cleaning and disinfection<br> Routine<br> Isolation

  Yes

  No

  N/A

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

  Yes

  No

  N/A

MEDICAL EQUIPMENT

• Glucometer supplies are dated with open and expiration dates

  Yes

  No

  N/A

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.

  Yes

  No

  N/A

• 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)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• No Multi-dose vials present in patient care areas

  Yes

  No

  N/A

OTHER

• Emergency Equipment checklist has daily documentation for all days open

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Eye wash logs present and completed weekly

  Yes

  No

  N/A

• Patient Food and drink appropriately labeled and not expired

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Laryngoscope blades are stored appropriately

  Yes

  No

  N/A