Date and Time of Audit:

Dates for Review:

Nurse Manager:


Staff Interviewed:


Patient MRN, age, and Initials:

Pre-Operative Documentation: Nursing
Record of Care:

• All entries are signed, dated , and timed
• Providers must document ID# after signature (required for orders).
• Write legibly.
• No prohibited abbreviations in the medical record.
• Verbal orders are co-signed by the end of the 3rd calendar day
• Corrections to hand written documentation are done in a compliant fashion.
Prohibited abbreviations include: U, IU, Q.D., Q.O.D., trailing zero ( x.0 mg), lack of leading zero ( .x mg), MS, MSO4, MgSO4

Include forms that are of clinical nature only (advance directive form, anesthesia pre-assessment, etc…). Do NOT include informed consents in this column (addressed later in the tool). Note patient signature is not required to be dated and timed)

Preferred Language:

Is the patient’s preferred language for discussing health care documented?

DNR Order:

DNR orders are either signed by the attending or if a verbal order, cosigned within 24 hours.
Look for any patient who is a DNR on the unit. If different from patient being audited, note the MRN in comments

Progress note discussing the DNR status is present in the EMR. If written by non-attending, note must be cosigned within 24 hours.


Pre-procedure checklist present?

Pre-Operative Documentation: Providers
Anesthesia Team:

Anesthesia Providers Name and Credentials:

Type of Anesthesia

Anesthesia Informed Consent:

Anesthesia Informed Consent is present?

Anesthesia informed consent is signed by Anesthesia/CRNA?

Anesthesia informed consent is dated and timed by Anesthesia /CRNA?

Witness signed the anesthesia informed consent?

Witness dated and timed the anesthesia informed consent?

Patient/Authorized representative signed the anesthesia informed consent?

Patient, witness and provider each date and time their own signatures only

Pre-Anesthesia Assessment

Pre-anesthesia/sedation assessment is documented within 48 hours prior to the surgery.

Pre-anesthesia assessment contains following elements:
• Heart
• Lungs
• Airway
• ASA classification
• Review of medical history ,including anesthesia, drug and allergy history
• Plan for anesthesia care
Paper ADR
Pre-procedure evaluation note for proceduralists

Anesthesia Time Out

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

Post Anesthesia Evaluation

Post-anesthesia evaluation documentation present

Post-anesthesia evaluation documentation is completed within 48 hours of the procedure

Required elements are documented:
• Respiratory function (respiratory rate, airway patency, oxygen saturation)
• Cardiovascular function (pulse rate and blood pressure)
• Mental status
• Temperature
• Pain
• Nausea and vomiting
• Postoperative hydration

Surgery Team:

Surgery Provider(s) Name and Credentials:

Procedure and Date of Procedure:

H&P: (Sunrise: H&P Provider notes in Sunrise for routine admissions (consult notes may be counted as H&P as long as all elements are present)

For procedures, Pre-procedure evaluation note may be used to document a full H&P, or an Update Note, or pre-anesthesia assessment (dependent on which is required)

H & P completed no more than 30 days before or 24 hours after patient admission.
History and physical contains the following minimum elements:
• Chief complaint or reason for admission or surgery
• Allergies
• Clinically significant adverse reactions and tolerances
• Current medications (may be in narrative note or reference to Rx Writer)
• Clinically pertinent physical and diagnostic findings, plan of care
• Plan of Care
• Examination of the heart, lungs, ASA and airway for patients having invasive procedures involving titrated (moderate or deep) sedation or anesthesia other than topical, local, or regional block.
Must be completed no more than 30 days before or 24 hours after patient admission or registration and must be documented within 24 hours after admission or registration, and before surgery/procedure requiring anesthesia or moderate/deep sedation (except for emergency procedures, may be done up to 24 hours after procedure).

“Outpatient Medication Status not yet specified” means Home Medication List not documented. If H&P does not have any indication of Home Medications, this would be non-compliant for this element

A pre-anesthesia assessment H&P completed on the day of surgery


H&P update note by JHH provider within 24 hours after admission and before surgery or procedure requiring sedation or anesthesiaH&P Update Note not required if full H&P done day of surgery (after registration).
The H&P update note must document these three required elements:
• The H&P was reviewed;
• The patient was examined;
• Either there were no changes that would influence the performance of the planned procedure or the following changes were noted (followed by a description of those changes).
Sunrise Document:
Update note or Pre-procedure evaluation note may be used to document Update Note,


Procedural Informed Consent present?

Procedure informed consent is signed by provider?

Procedure informed consent is dated and timed by provider?

Witness signed the procedure informed consent?

Witness dated and timed the procedure informed consent?

Patient/Authorized representative signed the procedure informed consent?

Patient, witness and provider each date and time their own signatures only

Procedure Informed Consent clearly documents the risks and benefits of the alternatives to the surgery?

Name of the procedure is documented on page 1 and 2 of the informed consent

Date field is completed on page 1

Procedural Time Out

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


The immediate post-op note/ brief op note is present

The immediate post-op note/brief-op note is written by a provider present for the procedure (as evident by Nursing Documentation of members present for surgery)

The immediate post-op note/ brief op note was completed immediately after procedure and before transfer to PACU or sending unit

Required elements are documented in the post/op note/brief-op note
• Surgeon and assistant names
• Procedure performed
• Pre-op diagnosis
• Post-op diagnosis
• Description of findings
• Estimated blood loss, if applicable
• Specimens removed, if applicable


The detailed post-op note is present

The detailed post-op note is finalized (not in draft) within 7 days of post-procedure?

Required elements are documented:
• All 7 elements specified for immediate post-op note PLUS:
• Detailed description of procedure
• Clinical stage of tumor as appropriate


Violent/Self-Destructive Patient Order within one hour of application of restraint
Look at all episodes of restraint for one day when auditing restraints
Indicate in comments any orders or face to face assessments that are not complete.
Mark as Not Met if less than 90% compliant for orders or face to face
Epic & Sunrise Document: Restraint Flowsheet
PAT003: Restraint and Seclusion, Management of Violent or Self-Destructive Patient

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

Violent/Self-Destructive Patient Orders every:
• 4 hours for adults > 18 yrs0
• 2 hours children 9-17 yrs
• 1 hour children < 9 yrs


Non-Violent Patient Initiation Order: Initiation order ASAP within one hour of restraint application and order matches type of restraint being documented.

Non-Violent Patient Continuation Orders - New order by the end of the calendar day and order matches type of restraint being documented.

Education (applies to violent and non-violent)

Patient education documented regarding reason for initiation of restraint.

Patient education documented regarding discontinuation criteria to be met in order to be released from restraints.


Restraint Plan of Care is documented daily with an appropriate time frame.

Nurse can speak to a behavior-driven reason that the patient is in restraints.
Standard PC.O3.05.01: The organization uses restraint or seclusion only when it can be clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others.


Nursing documentation reflects appropriate documentation
Q2 hrs for non-violent and q 15 mins for violent pt.
Review 24 hours of documentation or episode of care if less than 24 hours. Indicate in comments any missing assessments. Mark as yes, if compliant 90%
If patient’s behavior documented as calm, rationale for continued restraint is documented


Interview RN – ask the RN to identify the top problems that are keeping this patient in the hospital. Check the POC to determine if those problems are reflected.
Plan of Care = Nursing Assessment, Problem List, Treatment & Flows for implemented protocols, and Daily Goals Flow Sheet (which includes: Goal/Progress Toward Goal/Outcome, & Multidisciplinary Discharge Plan). Goals are documented within 24 hours of admit & progress toward goal is updated a minimum of daily and at transfer/discharges.

Nursing POC progress towards outcomes documented daily (review 3 days of documentation, starting on day two of admission).

Evidence of interdisciplinary care documented in chart

Evidence that the patient/ family is involved in the POC.


Admission Screening Note completed in POE within 24 hours of admission.
Initial assessment includes: (Contact person/telephone number, Source of information, Weight, Height (may be reported/estimated for adults)
Assessment Risk Screen * excludes NICU & newborn nursery except where indicated*
• Suspected abuse. Neglect/domestic violence
• Allergy(medication, food, environment, latex)
(Cultural, Dental/hearing/vision, Education/Communication (preferred language, communication needs, barriers to learning, Persistent/chronic pain, Religion (completed in NICU for neonates not born at JHH), Nutrition, Functional: PT/OT/SLP, Social Risk/discharge planning needs, Spiritual
Admission Risk Screen (Special Populations)
• Adolescent (13-17 yrs): Advance Directives and Smoking (13 and older); Substance Abuse (13-17yrs:provider completes this screen for adults
All obstetrical patients are screened throughout the continuum of care, which begins in the prenatal period and ends 6-8 weeks post-partum-inpatient documentation risk screening tool in QS will be completed OR validated from outpatient record
NICU Exceptions: Admission Screening Note (NICU) Per policy Policy CNDP100 and Policy PAT012 Appendix A: NICU exception:
The following items are completed in the NICU only if the baby was not born at JHH: Home Meds, Persistent/chronic pain, Religion
To be asked only if the baby has ever been discharged home: Suspected abuse/neglect/violence
Not applicable to NICU: PT/OT/SLP
Required specifically in NICU: Rule out metabolic disease, Likely to require or currently require parenteral nutrition.

Med Rec

Home medications are documented within 24 hours.

Medications documented on the Medication List contain the drug name, dose, frequency, and route.


Sunrise Patient Information Tab indicates patient was asked if they wanted emergency contact notified of admission


Look at the 3 most recent critical action values (CAV) in the pt’s chart; if unit RN accepted CAV(s), determine if there is a provider notification note indicating time provider notified.
For CAV, notification time should be within 1 hour of resulting. Ask RN which CAV results are under protocol. (Provider notification of protocol CAVs does NOT need to be documented). May require call to Pathology Customer Service (410-955-1921) to determine if the RN took the CAV.
Sunrise Document Documents Tab: Critical Action Note

(Fall Risk is not assessed in the NICU per Policy CNDP100.)

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

Appropriate documentation of fall interventions evident in the medical chart (and documented under the appropriate fall risk)

If patient had Companion/CPO- was there a provider order documented?


Learning Needs Assessment completed (Admission Screening note)

Unit Orientation

Safety Measures (includes pt ID, reporting concerns, prevention of infection, allergy band)


Central Line Education - FAQs About Catheter-Associated BSI

Keeping You Safe During Surgery and Procedures * found under handouts*

Anticoagulation education (Tips to Prevent Bleeding, Warfarin: Guide for Pts & Families)* For treatment only, N/A for prophylaxis*

Falls Education

Pain Management



Pain scale used is appropriate to the age and condition of the patient.

For patients with moderate or severe pain rating on admission (or if the patient requested pain to be addressed) was a pain goal obtained (for patients who can self-report and are greater than 7 years of age)

Pain rating documented within 1 hour prior to any PRN pain medications

Pain rating documented within 4 hours after administration of any PRN pain medications

Provider notifications documented per Pain Policy or Pain Order Sets (review 48 hours of documentation)

IV PCA (Adult)

Staff performs assessments a minimum of q2x2 after initiation, dose change, or bolus.

Staff performs assessments a minimum of every 4 hours when on a stable dose.

Provider notifications documented per Pain Policy or Pain Order Sets (review 48 hours of documentation)

For patients 18 years of age and older.

AD Notification Form is complete (Responsibility of Registration Staff-paper)
Registration Staff (Admitting Office, Patient Service Coordinators)
• Completion of the AD Notification Form and Patient Wishes Form
• Enter completion status into ADT system

Nurse Admission Screening Note indicates AD status

No discrepancies between AD Notification Form and Nurse Admission Screening Note

If patient has AD, copy of AD in chart or patient completed Patient Wish Form.

Medication Orders

Medications ordered as titrate have initial rate, parameters for titration, and therapeutic target.
Orders are written using the correct orderset, i.e., ICU ordersets are not used to write orders for patients on non-ICU floors

For titrated drugs, does the initial dose ordered match what was documented as the start dose?

The RN titrated the drug per ordered parameters.

Were the stat and now orders placed within the last 48 hours administered within the appropriate time frame?
Stat medication orders are administered within 30 minutes of order placement. Now orders are administered within 2 hours of order placement.

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.
RN can speak to appendix H in Medication Administration PAT 051 “Interpretation Guidelines for PRN Medications Orders for Same Indications

If an ordered medication has a dose range, does it specify starting dose and instructions for increasing the dose?

For range orders, was the order or policy followed?
For range orders, policy PAT036 dictates that the lowest dose is given first unless otherwise specified in the provider order

When required for high risk medications or per policy, RN co-signatures are present in the EMR.
Medication Administration, PAT 051, Appendix I lists medications that require independent double check. (i.e., Chemo, IV insulin, IV thrombolytics). Pediatric policy, GEN031, outlines medications that require independent double check for pediatric patients.

Chemotherapy Administration Adults

Chemotherapy Treatment Plan is in the patient's chart and signed by the Attending

Chemotherapy Checklist is completed prior to medication administration.

Medication CoSignatures are present per policy.

VAD Checklist

If patient had a central line inserted, is there a completed Central Line Checklist in the medical record?

“Central Line Insertion Care Team Checklist was completed” present in POE Procedure Note.

Advance Directives ( AD)

Staff able to verbalize process for assisting pt to obtain more information on advance directive.
Know to go to the Advance Directive policy - look for link in the additional resource section in the Patient Care Management section. Pt information can be printed from this link.


Verbalizes hand-off process (includes temporary hand-offs when caregiver off the unit)

Patient ID

Checks Safety Band for pt name and history # and compares it to source document (MAR, lab label, requisition) when giving med, blood, obtaining specimens or before procedure

Staff can identify their process for patients with same/similar names.

Reduce Risk of Infections

Additional Infection Risk Findings?

Staff can verbalize how they know unit equipment is clean and ready for use

Staff can verbalize appropriate contact time for all cleaning solutions used.

Staff can verbalize appropriate point of use pretreatment cleaning of instruments per IFUs (e.g., glidoscopes, scopes, instrument trays)

Staff practice hand hygiene when entering and exiting a room.

Staff appropriately gowned when pt on isolation precautions

Visitors adhere to isolation requirements.

Charge RN can verbalize how they know when a pt requires isolation
(At minimum, Charge RN can speak to ICO codes and HEIC fax/call)

Appropriate isolation signage is present

Staff can verbalize how to determine if negative pressure room is functioning appropriately

Biohazard signage is used for bio-hazardous material.

Biohazard signage is not present on non-bio-hazardous material.

Medical Equipment

Additional Medical Equipment Findings?

Staff able to verbalize procedure for broken equipment handling
(Hero Orange Tag vs Broken white Equipment Tag)

Glucometer supplies are dated with open and expiration dates

Medical equipment has clinical engineering services tag, clean, no sticky tape

Clean and dirty equipment are stored separately

Appropriate storage of oxygen tanks: Never used (as indicated by green cap over oxygen nozzle) separate from partially used and empty tanks)

Medical Equipment is plugged directly into wall outlet or plugged into a power strip that is permanently attached to the equipment assembly (e.g., a cart), with no daisy chaining of power strips (one power strip plugged into another power strip)


Label has medication name, strength, amount, diluents and volume (if not apparent from container) & exp date(if not used within 24 hrs or if expires < 24 hrs)

Staff checks the 5 rights, including 2 patient identifiers, prior to giving medication.

Verbalizes that RN drawing up med would not only label the medication appropriately but staff member who will be giving the med would verbally and visually verify it with person who drew it up

Insulin pens are labeled 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 medications found on unit (check pneumatic tube areas, emergency drug boxes, crash carts, pt care rooms for insulin pens, anesthesia carts if no staff in the room)

If the unit stores medications in individual patient rooms, meds are always secured and no meds are left in room after the patient is discharged.

Pill cutters are for individual patient use. If they are used for multiple patients, they do not contain residue.

Needles are kept secured unless area is monitored constantly.

Medication refrigerator has separate bins for insulin, neuromuscular blocking agents, (ICU, OR, procedure areas only), as well as “return to pharmacy” bin

Floor stock insulin is limited to aspart insulin in refrigerators on adult inpatient nursing units and either aspart or regular insulin on pediatric units. Other forms of insulin will be labeled patient specific or located within a Pyxis machine.
Only non-patient specific aspart insulin stored in inpatient refrigerators-all others in patient cassettes. NPH OK only for outpatient refrigerators.

Multi-use vials are labeled with 28 day expiration date and initials
Multi- use vials (includes insulin pens) expire 28 days after opening or manufacturer expired date, whichever comes first. If multi-dose vial is used and stored in an operating room, patient room, anesthesia cart, then the multi-dose vial needs to be dedicated to one patient

Multi-dose vials that are opened in immediate patient treatment areas (OR, patient room, clinic room, or procedure room) are treated as single-use vials (used for only one patient) and discarded at the end of the procedure.

Expired meds are segregated.

Staff can identify where P listed hazardous drugs are disposed of

Unit has a P-Listed disposal unit

Staff can identify common drugs that are disposed of as P waste


Staff able to verbalize when violent versus non-violent restraint protocol is used

RN able to speak to where brief-operative notes can be found

Staff can speak to QI and PI projects on their unit.

Emergency Equipment

Emergency Equipment checklist with daily documentation for all days opened

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

Patient Environment

Additional Patient Environment Findings?

Patient food and drink appropriately labeled and not expired
Juices expire 72 hours after opening. Patient food expires in 24 hours

Eye wash logs managed by nursing are present and completed weekly

All Red-Bag Trash cans have a lid and a red trash bag

Falls flag indicating moderate/high risk falls present

Blanket Warmer Cabinet set for <130 degrees Fahrenheit

Pull stations, electric panels and medical gas valves and panels are free from obstructions

Computers or patient equipment with PHI not in use are logged off

Emergency pull cords, in either exam rooms or patient bathrooms, are no more than 6 inches from the floor.

Emergency pull cords are not wrapped around hand rails

Alarm Response

Alarm response time is acceptable.

Staff can speak to process for managing response time to alarms

EVC Audit

EVC Staff Name:

Verbalizes the use of appropriate cleaning solutions per specific patient condition (e.g., oxivir for c-diff) or per unit environment (e.g., per HEIC, some units need to be cleaning all areas with Oxivir)

Verbalizes correct contact time for all cleaning solutions used

Verbalizes process for solutions, including toilet brushes.

Daily flushing of faucets and showers are documented on Water Flush Log.

Eye wash logs with weekly documentation present for EVC closet eyewashes.

Patient care areas are free of visible dirt, dust or stains.

Secondary containers (e.g., Wet Task buckets) are labeled with chemical name (date not required)

Wet Task bucket lids are kept closed when not in use

Verbalizes how to find information on any chemicals (SDS-Safety Data Sheet)

Verbalizes what to do in case of eye splash

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.