1.1 Is an agreed and documented clinical guideline available at the point of care?
1.2 Is the documentation on the clinical guideline for this patient completed, integrated and current for all pages reviewed as per the Clinical Documentation Policy?
1.3 Is the patient clinical record available to the clinical workforce at the point of care?
1.4 Is there evidence of legible signatures and role designation in patient clinical record for all relevant documentation reviewed? If not, state what is missing.
1.5 Is there an informed consent form in the patient medical record that has been completed according to RHC GCG:01:020:01:OOG RHC Consent Request for Medical Treatment?
1.6 Is there evidence in the patient medical record of progress notes using the SOAP format (PT and OT)?
1.7 Is there evidence that documentation includes approved abbreviations contained in the HIMAA Australian Dictionary of abbreviations, acronyms and symbols. If not, state examples of incorrect abbreviations.
1.8 Is there evidence in the patient medical record that all assessments relevant to the patient’s admission have been completed within the required timeframes as per Hospital policy (includes FIM (72 hrs), nursing (24 hrs), medical (24 hrs) and allied health (PT 24 hrs; OT 2 working days).
1.9 Is there evidence that length of stay has been discussed with the patient at Admission?
1.13 Any variances in patient's condition are to be documented in the progress notes.
1.10 Clinical Documentation - signature and designation following each entry into the progress notes.
1.11 Clinical Documentation - Interventions have documented times / amounts where indicated.
1.12 Variances in patient's condition are recorded in the progress notes.
3.1 Is PPE available at the bedside? Is it being used in accordance with RMM.01.17 Infection Control Standard Precautions and HICMR Policy 2.8P Standard Precautions?
3.2 If patient has a known infection status, are appropriate transmission based precautions in use? Is there adequate stock of the appropriate attire readily available?
3.3 Is an alcohol based hand rub within this patient area?
3.4 Do patients and visitors have access to hand hygiene products?
3.5 If patient is immobile ask patient – “Were you offered or assisted to wash your hands after toileting?”
3.6 Is a sharps disposal bin available at the point of use, in accordance with HICMR Policy 8.1P Clinical and Related Waste Management?
3.8 Is the patient area / environment clean and free of dust?
3.7 Is there an intravascular device insitu, for example, CVC, PICC, IVC?
3.7.1 Site Inspection: Is the device dressed with the site visible? Is the dressing dry and intact? Does the patient shows signs and symptoms of infection?
3.7.2 Documentation: Have site inspections and flushes been documented as per GPC.08.04 Short Peripheral Cannulas: Insertion & Management? Are the insertion details (including date, device and site) documented in the progress notes/admission notes/clinical pathway? Length of time device insitu (days/hours)? Is the length of time the device has been in situ compliant with GPC.08.04 Short Peripheral Cannulas: Insertion & Management?
3.9 Is there access to a clinical hand-wash basin nearby?
3.10 Is medical equipment in use clean (e.g. infusion pumps)?
3.11 Are there detergent wipes or cleaning solution available to clean equipment?
3.12 Has the patient been screened for healthcare associated infections or communicable diseases? (Check preadmission and/or admission paperwork, MR3.01 Alert Notification)
4.1 Not applicable to MWP
4.2 Is the patient identification complete on ALL pages of the NIMC?
4.3 Is the allergy and adverse drug reaction (ADR) section on the NIMC completed in full, including documentation of nil known/unknown?
4.4 If the patient does have a documented known allergy or previous adverse drug reaction, has this medication been prescribed by a medical officer?
4.5 If the medication has been prescribed, has the medication been administered to the patient?
4.6 Is the medication history documented on the NIMC and/or the progress notes?
4.7 Is the medication chart easily accessible at the patient bedside?
4.8 Are telephone orders signed by the treating doctor in accordance with GPC.09.09 Medication Administration?
4.9 Has a VTE Risk Assessment been completed as per RHC GCG:001:013:13:OOG Venous Thromboembolism Risk Assessment Policy?
4.10 If chemical VTE prophylaxis was required as per VTE risk assessment, has this been prescribed?
4.11 Are there any medications left unattended at patient bedside?
4.12 If medications are present in the room, are they stored appropriately as per GPC.09.09 Medication Administration?
4.13 Are all IV lines/bags etc. labelled in accordance with ACSQHC National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines?
5.1 The patient identification band is used to identify the patient? Refer RHC GCG01:013:02:OOP Patient Identification Policy
5.2 Are the details on the patient identification band correct? (ask patient to state name, DOB)
5.3 Is there only one identification band on the patient?
5.4 Is the identification band either red or white?
- Patient's name
5.6 Are the patient identifiers written in black text on a white background?
5.7 Ask the patient “Have staff checked your arm band?”
- Shift change
- Inter-hospital transfer
- Face to face
- Via phone
- Via written orders
6.3 Where is clinical handover occurring for this patient?
6.4 Was patient identification established at the commencement of handover?
6.5 Was the handover of patient information carried out as per GPC.23.03 Clinical Handover Policy? (effective; responsibility; accountability for care)
6.6 Was the patient / carer involved in the handover process?
6.7 Is a structured tool used for clinical handover? (i.e. Clinical Handover Sheet, SHARED Communication Tool.)
6.8 Is there evidence of verification of clinical handover in the medical record for interhospital transfers (e.g. interhospital transfer forms, discharge summaries, patient care pathways)? State the evidence of this happening.
6.9 Is there evidence that patient SMART goals have been established and progress towards them discussed at a multidisciplinary case conference led by the Rehabilitation Physician? ( Case Conference booklet).Goals - (s) Specific, (M) Measurable,(A) Achieveable,(R) Realistic, (T) Time specific
6.10 Is there evidence that the Discharge checklist has been updated at case conference by all disciplines? If no, state what is missing.
6.11 Has the discharge checklist has been completed ? If no, state what is missing.
7.1 Have two (2) people checked patient identification at patient bedside prior to administration of blood/blood product? (review the patient record)
7.2 Is there documented evidence of informed consent for the administration of blood/blood products?
7.3 Is there documented evidence of blood prescription?
7.4 Is there documented evidence of relevant blood product information (ie. Blood bank numbers / product ID / batch number / blood transfusion compatibility label)?
7.5 Was written information given to the patient (ask patient/review patient record)?
7.6 Was information provided to the patient verbally?
7.7 Did the patient understand the information (ask patient)?
7.8 Were observations conducted according to hospital policy?
7.9 Did the patient experience any adverse reactions? If yes, state what happened.
7.10 Was the adverse reaction managed as per hospital policy?
7.11 Was the adverse reaction reported to the laboratory (check documentation)?
7.12 Was the adverse reaction entered into Riskman? if yes, state the Riskman incident number
7.13 Was the adverse reaction recorded in the patient's notes?
8.1 Is there documented evidence of a risk assessment determining the patient’s level of risk for developing a pressure injury using a risk assessment tool as per RHC GCG 01:013:07:OOP Pressure Injury Risk Assessment
8.2 Has the pressure injury risk been reassessed in response to a change in patient condition during the episode of care? If there has been no change, select N/A
8.3 Can the patient independently reposition themselves?
8.4 Is there a documented pressure injury prevention plan in the patient's progress notes?
8.5 Has the pressure injury prevention plan been developed in partnership with patient and carers? (Check the patient notes)
- daily skin assessments
- recording patient skin condition
- malnutrition risk assessment
- protective padding
- repositioning regime
- reduce exposure to moisture
8.7 Are pressure reducing/relieving device(s) in use for patients who have been assessed as at risk?
- comfort/adjunct devices
- static cushions
- dynamic cushions
- static overlays
- dynamic overlays
- air matresses
- speciality bed
- heel aids
8.9 If the patient has a pressure injury is there a documented wound assessment and management plan in the patient notes?
8.10 If the patient has a pressure injury, is there documentation related to the progress of the pressure injury within the last five (5) days? If not, state why.
8.11 Was an entry in RiskMan entered for any hospital acquired or worsening of pressure injury present on admission?
8.12 Was the patient assessed as being “at risk of pressure injury”, given any written information on pressure injury? (ask patient)
8.13 Was the patient’s weight recorded on admission?
8.14 If the length of stay is greater than 7 days, has a follow up weight been recorded for patients at risk?
8.15 Was the patient screened for malnutrition risk on admission?
8.16 If the patient is at risk of malnutrition, has a referral to a dietician been made?
8.17 If the patient is at risk of malnutrition, is there a documented nutrition care plan in the patient's notes? (diet supplements, monitoring intake/weight?)
9.1 Does the patient have a current Not for Resuscitation order or Advanced Health Directive recorded in the patient notes/ (MR 24.1 Instructions for Withholding/Withdrawing Life Sustaining Treatment?)
9.2 Is a Track and Trigger observation chart in use?
- Respiratory rate
- Oxygen saturation
- Heart rate
- Blood pressure
- Level of consciousness
9.4 Does the last set of observations documented include all core physiological observations selected above? If no, state what was missing.
9.5 Were core observations measured according to the minimum frequency specified in the monitoring plan or hospital policy for the last 24 hours?
9.6 Were there any abnormal vital signs recorded in the last 24 hour period?
9.7 If there are abnormal vital signs, is there evidence of escalation response as per actions required on MR6.01 EWS Chart?
9.8 Have the patient, family members and/or carers been educated on how to communicate concerns about potential deterioration of the patient? (ask patient / family members / carers)
10.1 Was the patient screened for risk of falling using MR6.05 Falls Risk Assessment?
10.2 Is there a documented multifactorial falls prevention plan of care which includes strategies to reduce the identified falls risks?
10.3 Is there evidence that the falls prevention plan has been developed in partnership with patient and carers?
10.4 Has care been provided according to the falls prevention plan?
10.5 If a mobility aid is required, is it within reach of the patient?
10.6 Is the nurse call system within reach of the patient?
10.7 Can the patient demonstrate how to use the nurse call system? If no, state why.
10.8 Has the patient had a fall since being in hospital? Ask patient/state details
10.9 Was the fall documented in RiskMan? (If yes, state the RiskMan Incident Number)
10.10 Was the fall documented in the patient’s notes?
10.11 Were fall prevention strategies implemented to reduce risk of repeated fall?
10.12 Is there evidence of a Falls Sticker in the progress notes with a relevant explanation and plan of action.
10.13 Has the falls risk been re-assessed in response to a change in patient condition and/or a fall as per GPC.10.02 Patient Falls Management Policy? If there is no change/fall, select N/A
10.14 Is the patient’s environment free of fall or trip hazards? If no, state the hazard.
10.15 Has the patient been given information on falls prevention? (ask the patient)
10.16 Has the patient’s falls risk been documented in the discharge plan and relevant referrals made to community agencies, GP and/or allied health services?