Information
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Audit Title
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Document No.
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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
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1 - Staff can easily locate:<br> H&P, falls Risk Assessment, Pain<br> Assessment/Reassessment, EC Record etc?
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2 - No use of unapproved abbreviations (Last 72 hours)?<br><br>Check hard chart
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3 - Review entries in the medical record of date, time and signature (Last 72 hours).<br><br>Check hard chart
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4 - Informed consents are signed, witnessed and date and timed (review all consent forms).<br><br>Check hard chart
Patient Safety/National Patient Safety Goals
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5 -<br>Universal Protocol/Time Out: Document?<br>(if pt any procedures)
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6 - Was patient screened for suicide?<br>Review Documentation-
Provision of Care Treatment and Services
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7 - Plan of Care documented and updated per patient's diagnosis & current conditions?<br>(Review 3 days of documentation, starting on day two of admission).<br><br>Note: Multi-disciplinary rounds vary from unit to unit - discuss documentation of rounds with RN<br>Plan of care = Nursing assessment, problem list, treatment & flow for implemented protocols, and daily goals flow sheet (which includes: goal/out & multidisciplinary discharge plan). Goals are documented within 24 hours of admit & progress toward goal is updated ongoing and at transfer/discharge
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8 - Evidence of interdisciplinary care documented in chart?
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9 - Is a history & physical complete and filled on the chart within 24 hours of admission?
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10 - Was the nursing assessment completed within 24 hours?
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11 - Was a nutrition screen completed within 24 hours of admission
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12 - where is the falls risk documented?
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13 - Is there a physician's progress note for each day of admission?
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14 - Does the Interdisciplinary Education sheet reflect any teaching to date?
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15 - Look at any 3 critical tests and results in the pt's chart; if unit RN accepted critical results, determine if there is a provider notification note indicating time provider was notified needs to be within 30 minutes
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16 - Routine pain assessment: Staff performs assessment a minimum of every 4-6 hours per routine pain rating assessment<br><br>Post PRN doses of pain medication:<br> Within 1 hour after any analgesic or local anesthetic including PRN & scheduled medications.<br><br>A. Pain Assessment Score on a 0-10 scale are rated as:<br> 1. Mild pain is: 1-3 out of 10<br> 2. Moderate pain is: 4-6 out of 10<br> 3. Severe pain is: 7-10 out of 10
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17 - There are restraint order (s) that cover each episode of restraints (Check for 72 hr period)<br><br>Nursing documentation reflects appropriate documentation per restraint flow sheet<br> a) Every 4 hours for ages 18 and over<br> b) Every 2 hours for ages 9-17<br> c) Hourly for under 9 years
Infection Prevention
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18 - Is patient in isolation? If yes, does patient Cerner isolation order and does it match the sign at the bedside?
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19 - Is pt an MDR pt? Is pt in Isolation?
Medication Management
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20 - Home Medication List completed within 24 hours
Rights and Responsibilities of the Individual
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21 - Learning Needs Assessment completed ( on Admission Record Note)<br><br>Unit Orientation (ad hoc education)<br><br>Safety Measures (includes pt ID, reporting concerns, preventing of infection, allergy band)
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22 - Look for specific education documentation on the below topics<br><br>1. Central Line Education - FAQ About Catheter-Associated BSI (when applicable)<br><br>2. Keeping You Safe During Surgery and Procedures<br><br>3. Anti coagulation education (Tips to Prevent Bleeding, Warfarin: Guide for Pt's & Families (when applicable)<br><br>4. Falls Education (activity/mobility)<br><br>5. Pain Management
Describe the Unit's response to your arrival
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23 - Greet the team with smiles & introductions
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24 - Have a space designated for team to conduct interviews and file reviews?
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25 - Promptly deliver materials required for review to the tracer team?
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26 - Any additional comments regarding positive or suboptimal issues observed during this tracer?
