Audit

Documentation

Record of Care
• All entries are signed, dated , and timed
• Write legibly.
• No prohibited abbreviations in the medical record.
• Verbal orders are co-signed within 48 hours.
• Provider orders will reflect prescriber’s signature and credentials.
1. If the order is entered electronically the signature is automatically captured.
2. If the order is written it must also include one of the following: a Sibley name stamp (preferred); a legibly printed first and last name, pager number/phone number.

Prohibited abbreviations include: U, IU, Q.D., Q.O.D., trailing zero ( x.0 mg), lack of leading zero ( .x mg), MS, MSO4, MgSO4

The H&P should include pertinent elements of the:

1. History and Physical Examination (H&P) for Inpatient Care .
• Chief complaint;
• History of present illness;
• Past medical history including a history of allergies, current medications, previous significant illnesses and hospitalizations, previous surgeries and reactions to anesthesia, development, and diet;
• Review of systems;
• Family history;
• Social history;
• Physical examination;
• Assessment that includes a list of problems; and
H&P
• Plan for the diagnostic evaluation and therapeutic interventions. If surgery is to be performed, the record shall contain the indications for surgery.
In patient; H & P completed no more than 30 days before or 24 hours after patient admission and before surgery or a procedure requiring anesthesia services (except for emergency procedures, may be done up to 24 hours after procedure).

An H&P performed by a resident or physician extender (ARNP/Physician Assistant) is acceptable as long as an attending physician from the service of record cosigns the H&P within twenty-four (24) hours.

H&P UPDATE NOTE
H&P update note by provider within 24 hours after admission and before surgery
• For a medical history and physical examination that was completed within 30 days prior to inpatient admission, an update documenting any changes in the patient’s condition is completed within 24 hours after inpatient admission or prior to an invasive procedure or surgery.

H&P Update Note not required if H&P done day of surgery.

Chart Review activity – Notes tab – Note Type: H&P

PHYSICIAN PROGRESS NOTES
Physician’s progress note for each day of admission
Progress Notes
A physician from the service of record must complete a physician progress note at least daily for critically ill patients and no less than every two days for all other patents. A progress note entered by a physician extender (ARNP, Physician Assistant) in lieu of a physician progress note is acceptable as long as a supervising physician documents that he/she has evaluated the patient and reviewed the physician extender’s progress notes, orders, and plan of care. If the physician extender is only entering orders, then the supervising physician’s daily progress note shall include a notation that he/she has reviewed the physician extender’s orders.

Progress notes in the paper chart should be legible and all paper and electronic progress notes should include:
• A review of the patient's progress since the last evaluation;
• Pertinent interval examination;
• Pertinent problems and status;
• Results of tests and treatments;
• Plans including diagnostic testing and therapies; and
• Date, time, name of service, and signature of practitioner.

Chart Review activity – Notes tab – Note Type Progress Notes
“Progress notes shall be written daily on critically ill patients and those where there is difficulty in diagnosis or management of the clinical problem. All other patients should have a progress note no less than every two (2) days.”
(MS Rules and Regs Page 13, G. Progress Notes)

HOME MEDICATION LIST COMPLETED and MEDICATION RECONCILIATION
Home medication list completed as appropriate. Medication history reviewed on admission and prior to discharge.
Update home medication list required if any medication changes

Nursing: Admission navigator – Review Home Meds
Provider: Admission navigator – Admission Med Rec


(Med Rec policy 03-21-37 does not include a time frame)

ALLERGIES
Food and drug allergies are addressed in the medical record
Can be found in: Patient Header (also in the Admission navigator)

PREOP CHECKLIST
Preoperative checklist completed by sending unit
Can be found in: Nursing: Flow sheets – Pre-op Checklist tab

PRE-PROCEDURE (PRE-OP) NURSING ASSESSMENT
Pre-Procedure/Sedation
• Last oral intake
• Baseline vital signs (pre-procedural temperature, oxygen saturation, LOC, and pain score, weight)
• Medication history
• Allergies
• Pregnancy status
• Exposure to infectious disease and isolation precautions as needed
• Patency of IV
• Location of recovery
• Name, phone number of family member on-site

Can be found in: Nursing: Flowsheets – Intake/Output, Vital signs (VS Complex), Admission navigator, IV Assessment, Patient Header, ADT Events in Overview/Handoff Report, Pre-Op navigator – Discharge Plan/Ride Home

PREPROCEDURE CHECKLIST / TIME-OUT
Pre-procedure verification is completed before the patient leave the pre-op area.
Time out is documented
Can be found in: Flowsheets - Pre-op Checklist and Time Out flowsheet tabs




DISCHARGE SUMMARY DOCUMENTED (physician)
Discharge Summary

A discharge summary shall be dictated or otherwise completed electronically for all patients hospitalized for more than forty-eight (48) hours. A final progress note may be substituted for the discharge summary for uncomplicated stays of forty-eight (48) hours or less. The discharge summary should include:

• The reason for hospitalization;
• All established diagnoses;
• Operation and/or procedure performed;
• Hospital course;
• Physical exam of the patient at discharge;
• Disposition of patient at discharge;
• Discharge instructions; and
• A complete list of all medications
• Co-signature by a physician for discharge summaries prepared by an ARNP or PA is required within seven (7) days of discharge.
Can be found in: Chart Review - Notes tab – Note type: Discharge Summaries

Restraint Documentation

RESTRAINT ORDERS: VIOLENT
Behavioral (Violent/Self-Destructive) Patient Orders every:
• 4 hours for patients > 18 yrs
• 2 hours for patients 9-17 yrs
• 1 hour for patients < 9 yrs
Can be found in: Chart Review – Other Orders tab

RESTRAINT ORDERS: VIOLENT
Violent/Self-Destructive Patient Evaluation
• In-person face-to-face evaluate by LIP within 1 hour of initiation of restraints and of patient’s immediate situation
• Nursing assessment/reassessment every 15 minutes
Can be found in: Chart Review – Other Orders tab

RESTRAINT ORDERS: NON-VIOLENT
Clinical (Non-Violent/Non-self-destructive) Patient Orders - new order every 24 hours
Can be found in: Chart Review – Other Orders tab

RESTRAINT ORDERS: NON-VIOLENT
Non-Violent Patient Evaluation
Nursing documentation reflects appropriate assessment/reassessment documentation indicated on flowsheet every 2 hours
Can be found in: Chart Review – Other Orders tab

RESTRAINTS
Nursing documentation reflects appropriate documentation

Q2 hrs for non-violent and q 15 mins for violent pt
Can be found in: Flowsheets – Non-Violent Restraints or Violent/Short Term Hold Restraints tabs respectively

Nursing Non-Procedural Documentation

ADMIT SCREEN
Admission Screening completed within 24 hours of admission.
Initial assessment includes:
• For patients receiving end-of life-care the social, spiritual, and cultural variables that influence the patient and families perception of grief.
• Contact person/telephone number
• Home medications/supplements
• Source of information
• Weight
• Height (may be reported/estimated for adults
• Smoking
• Preferred language
Assessment Risk Screen
• Suspected abuse. Neglect/domestic violence
• Suicide
• Flight risk
• Allergy(medication, food, environment, latex)
• Cultural
• Dental/hearing/vision
• Education/Communication (preferred language, communication needs, barriers to learning)
• Persistent/chronic pain
• Nutrition
• Functional: PT/OT/SLP
• Social Risk/discharge planning
• Spiritual
• Skin breakdown (Braden Q)
• A nutritional screening, when warranted by the patients’ needs or condition, is completed within 24 hours of inpatient admission.

Allergies are reviewed each episode of care (inpatient or outpatient)

Can be found in: Nurse’s Admission navigator – Admission Screening section for all elements except for the following:
Preferred language – documented in Demographics and appears in the patient header if non-English preferred.


PLAN OF CARE
Nursing Plan of Care documented and updated per pt’s diagnosis and current condition (review 3 days of documentation, starting on day two of admission).

NOTE: Multi-disciplinary rounds vary from unit to unit- discuss documentation of rounds with RN.
Can be found in:
Summary activity – Multi-Disciplinary POC report (pulls in all Nursing and Ancillary disciplines documentation with a link to Providers Notes)
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 ongoing and at transfer/discharges.

PLAN OF CARE
Evidence of interdisciplinary care documented in chart
Can be found in: Summary activity – Multi-Disciplinary POC report (pulls in all Nursing and Ancillary disciplines documentation with a link to Providers Notes)

FALL PROTOCOL
Fall risk assessment done q day (review 72 hours of charting)
• All inpatients will be assessed on admission using the Fall Risk Assessment Form in the medical record.
Appropriate documentation of fall interventions evident in the medical chart
o Inpatients – document in medical record:
 Fall Risk Assessment form
 Standard Safety Measures
 Fall risk interventions
 Patient/family education
Can be found in: Flowsheet activity – Assessment tab

PATIENT EDUCATION
Learning Needs Assessment completed (Admission Screening note)
Can be found in: Education activity – Education Review tab (check Unresolved, Resolved and Deleted) and Expand All (upper left).



Review pt chart for documentation of required education

PATIENT EDUCATION
Admission Education completed:
• Unit Orientation
• Safety Measures (Includes pt ID, reporting concerns, prevention of infection, allergy band)
• Isolation (if applicable)
Can be found in: Education activity – Education Review tab (check Unresolved, Resolved and Deleted) and Expand All (upper left).



Review pt chart for documentation of required education

PATIENT EDUCATION
Isolation
Can be found in: Education activity – Education Review tab (check Unresolved, Resolved and Deleted) and Expand All (upper left).
Review pt chart for documentation of required education

PATIENT EDUCATION
Central Line Education
Can be found in: Education activity – Education Review tab (check Unresolved, Resolved and Deleted) and Expand All (upper left).
Review pt chart for documentation of required education

PATIENT EDUCATION
Keeping You Safe During Surgery and Procedures
Can be found in: Education activity – Education Review tab (check Unresolved, Resolved and Deleted) and Expand All (upper left).
Review pt chart for documentation of required education

PATIENT EDUCATION
Anticoagulation education (Tips to Prevent Bleeding, Warfarin: Guide for Pts & Families
Can be found in: Education activity – Education Review tab (check Unresolved, Resolved and Deleted) and Expand All (upper left).
Review pt chart for documentation of required education

PATIENT EDUCATION
Falls Education
Can be found in: Education activity – Education Review tab (check Unresolved, Resolved and Deleted) and Expand All (upper left).
Review pt chart for documentation of required education

PATIENT EDUCATION
Pain Management
Can be found in: Education activity – Education Review tab (check Unresolved, Resolved and Deleted) and Expand All (upper left).
Review pt chart for documentation of required education

PATIENT EDUCATION
Education documentation completed on all shifts
Can be found in: Education activity – Education Review tab (check Unresolved, Resolved and Deleted) and Expand All (upper left).
Review pt chart for documentation of required education

PAIN ASSESSMENT
Routine pain assessment:
Staff performs assessments based on pain scale used and last score
• Per policy, pain will be assessed and documented:
o At least every shift using appropriate Pain Assessment Tool.
Post scheduled dose of pain medication:
Staff performs assessments a minimum of once per shift per routine pain rating assessment
• Per policy, pain will be assessed and documented:
o When pain is present, location and descriptors are documented each shift and as condition changes.
o Within 1 hour after any analgesic or local anesthetic including prn & scheduled medications.
o Rehabilitation Services will assess and document pain assessment prior and after non-pharmacologic interventions they provide.
Can be found in: Summary activity – Pain report (shows pain documentation associated with pain med administration)
Note: “Patient asleep” does not show on clinical measures

ADVANCE DIRECTIVES (AD)
AD Notification Form is complete (Responsibility of Registration Staff)
Can be found in: Demographics activity
Nurses Admission navigator – Healthcare Directives section

ADs not required for Outpatients. Upon request, the hospital refers the patient to resources for assistance to formulate AD.

ADVANCE DIRECTIVES (AD)
Nurse Admission Screening: Note indicates AD status
Can be found in: Demographics activity
Nurses Admission navigator – Healthcare Directives section

ADs not required for Outpatients. Upon request, the hospital refers the patient to resources for assistance to formulate AD.

ADVANCE DIRECTIVES (AD)
No discrepancies between AD Notification Form and Nurse Admission Screening Note
Can be found in:
Demographics activity

Nurses Admission navigator – Healthcare Directives section

ADs not required for Outpatients. Upon request, the hospital refers the patient to resources for assistance to formulate AD.

ADVANCE DIRECTIVES (AD)
If patient has AD, copy of AD in chart.
Can be found in:
Demographics activity
Nurses Admission navigator – Healthcare Directives section

ADs not required for Outpatients. Upon request, the hospital refers the patient to resources for assistance to formulate AD.

Did patient have surgical procedure or receive anesthesia for any reason during this admission?
If so, please complete the following:

POST-ANESTHESIA EVAL
REQUIRED elements 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
• Description of complications or anesthesia reactions (when applicable)
Can be found in:
Chart Review – Anesthesia Records tab

IMMEDIATE POST-OP NOTE
REQUIRED elements documented immediately after the procedure:
• Surgeon and assistant names
• Procedure performed
• Description of findings
• Post-op diagnosis
• Estimated blood loss
• Specimens removed
Can be found in:
Chart Review – Notes tab – Note Type: Brief Op Note

The report may be written in the next area of care if the proceduralist accompanies the patient to the next level of care.

DETAILED POST-OP NOTE
REQUIRED elements documented:
• Surgeon and assistant names
• Procedure performed
• Description of findings
• Post-op diagnosis
• Estimated blood loss
• Specimens removed
• Detailed description of procedure
Can be found in:
Chart Review – Notes tab – Note Type: Operative Note

DESCRIBE THE UNIT’S RESPONSE TO YOUR ARRIVAL

Greet the team with smiles & introductions?

Have a space dedicated for the team to conduct interviews and file reviews?

Promptly answer questions or deliver materials required for review to the tracer team?

Any additional comments regarding positive or suboptimal issues observed during this tracer?

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.