Mt Wilga Private Hospital Bedside Audit Tool

• Audit Title (type doc number and ward e. 45-JGW)

• Document No.

• Ward

  BNW

  JGW

  KBW

• Patient MRN

• Audit Conducted by (Type name of auditor)

• Conducted on

  Date

Standard 1 - Governance for Safety and Quality in Health Service Organisations

• 1.1 Is an agreed and documented clinical guideline available at the point of care?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• 1.3 Is the patient clinical record available to the clinical workforce at the point of care?

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• 1.6 Is there evidence in the patient medical record of progress notes using the SOAP format (PT and OT)?

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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).

  Yes

  No

  N/A

• 1.9 Is there evidence that length of stay has been discussed with the patient at Admission?

  Yes

  No

  N/A

• 1.13 Any variances in patient's condition are to be documented in the progress notes.

  YES

  NO

  N/A

• 1.10 Clinical Documentation - signature and designation following each entry into the progress notes.

  Yes

  No

  N/A

• 1.11 Clinical Documentation - Interventions have documented times / amounts where indicated.

  Yes

  No

  N/A

• 1.12 Variances in patient's condition are recorded in the progress notes.

  YES

  NO

  N/A

Preventing and Controlling Healthcare Associated Infections

• 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?

  YES

  NO

  N/A

• 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?

  YES

  NO

  N/A

• 3.3 Is an alcohol based hand rub within this patient area?

  Yes

  No

  N/A

• 3.4 Do patients and visitors have access to hand hygiene products?

  Yes

  No

  N/A

• 3.5 If patient is immobile ask patient – “Were you offered or assisted to wash your hands after toileting?”

  YES

  NO

  N/A

• 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?

  Yes

  No

  N/A

• 3.8 Is the patient area / environment clean and free of dust?

  Yes

  No

  N/A

• 3.7 Is there an intravascular device insitu, for example, CVC, PICC, IVC?

  Yes

  No

  N/A

• 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?

  YES

  NO

  N/A

• 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?<br>

  YES

  NO

  N/A

• 3.9 Is there access to a clinical hand-wash basin nearby?

  Yes

  No

  N/A

• 3.10 Is medical equipment in use clean (e.g. infusion pumps)?

  YES

  NO

  N/A

• 3.11 Are there detergent wipes or cleaning solution available to clean equipment?

  YES

  NO

  N/A

• 3.12 Has the patient been screened for healthcare associated infections or communicable diseases? (Check preadmission and/or admission paperwork, MR3.01 Alert Notification)

  Yes

  No

  N/A

Standard 4 - Medication Safety

• 4.1 Not applicable to MWP

  Yes

  No

  N/A

• 4.2 Is the patient identification complete on ALL pages of the NIMC?

  Yes

  No

  N/A

• 4.3 Is the allergy and adverse drug reaction (ADR) section on the NIMC completed in full, including documentation of nil known/unknown?

  Yes

  No

  N/A

• 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?

  YES

  NO

  N/A

• 4.5 If the medication has been prescribed, has the medication been administered to the patient?

  YES

  NO

  N/A

• 4.6 Is the medication history documented on the NIMC and/or the progress notes?

  Yes

  No

  N/A

• 4.7 Is the medication chart easily accessible at the patient bedside?

  Yes

  No

  N/A

• 4.8 Are telephone orders signed by the treating doctor in accordance with GPC.09.09 Medication Administration?

  YES

  NO

  N/A

• 4.9 Has a VTE Risk Assessment been completed as per RHC GCG:001:013:13:OOG Venous Thromboembolism Risk Assessment Policy?

  Yes

  No

  N/A

• 4.10 If chemical VTE prophylaxis was required as per VTE risk assessment, has this been prescribed?

  YES

  NO

  N/A

• 4.11 Are there any medications left unattended at patient bedside?

  Yes

  No

  N/A

• 4.12 If medications are present in the room, are they stored appropriately as per GPC.09.09 Medication Administration?

  Yes

  No

  N/A

• 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?

  YES

  NO

  N/A

Standard 5 - Patient Identification and Procedure Matching

• 5.1 The patient identification band is used to identify the patient? Refer RHC GCG01:013:02:OOP Patient Identification Policy

  Yes

  No

  N/A

• 5.2 Are the details on the patient identification band correct? (ask patient to state name, DOB)

  Yes

  No

  N/A

• 5.3 Is there only one identification band on the patient?

  Yes

  No

  N/A

• 5.4 Is the identification band either red or white?

  Yes

  No

  N/A

• 5.5 What core patient identifiers are present on the identification band? Select ALL patient identifiers that are present

  Select Patient's name DOB MRN

  • Patient's name
  • DOB
  • MRN

• 5.6 Are the patient identifiers written in black text on a white background?

  Yes

  No

  N/A

• 5.7 Ask the patient “Have staff checked your arm band?”

  Yes

  No

  N/A

Standard 6 - Clinical Handover

• 6.1 In what instance is clinical handover occurring for this patient?

  Select Shift change Inter-hospital transfer Admission Discharge

  • Shift change
  • Inter-hospital transfer
  • Admission
  • Discharge

• 6.2 What is the method of clinical handover for this patient?

  Select Face to face Via phone Via written orders

  • Face to face
  • Via phone
  • Via written orders

• 6.3 Where is clinical handover occurring for this patient?

  Patient bedside

  Corridor

  Nurses room

  Staffroom

• 6.4 Was patient identification established at the commencement of handover?

  Yes

  No

  N/A

• 6.5 Was the handover of patient information carried out as per GPC.23.03 Clinical Handover Policy? (effective; responsibility; accountability for care)

  Yes

  No

  N/A

• 6.6 Was the patient / carer involved in the handover process?

  Yes

  No

  N/A

• 6.7 Is a structured tool used for clinical handover? (i.e. Clinical Handover Sheet, SHARED Communication Tool.)

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• 6.10 Is there evidence that the Discharge checklist has been updated at case conference by all disciplines? If no, state what is missing.

  Yes

  No

  N/A

• 6.11 Has the discharge checklist has been completed ? If no, state what is missing.

  Yes

  No

  N/A

Standard 7 - Blood and Blood Products

• 7.1 Have two (2) people checked patient identification at patient bedside prior to administration of blood/blood product? (review the patient record)

  YES

  NO

  N/A

• 7.2 Is there documented evidence of informed consent for the administration of blood/blood products?

  YES

  NO

  N/A

• 7.3 Is there documented evidence of blood prescription?

  YES

  NO

  N/A

• 7.4 Is there documented evidence of relevant blood product information (ie. Blood bank numbers / product ID / batch number / blood transfusion compatibility label)?

  YES

  NO

  N/A

• 7.5 Was written information given to the patient (ask patient/review patient record)?

  YES

  NO

  N/A

• 7.6 Was information provided to the patient verbally?

  YES

  NO

  N/A

• 7.7 Did the patient understand the information (ask patient)?

  YES

  NO

  N/A

• 7.8 Were observations conducted according to hospital policy?

  YES

  NO

  N/A

• 7.9 Did the patient experience any adverse reactions? If yes, state what happened.

  YES

  NO

  N/A

• 7.10 Was the adverse reaction managed as per hospital policy?

  YES

  NO

  N/A

• 7.11 Was the adverse reaction reported to the laboratory (check documentation)?

  YES

  NO

  N/A

• 7.12 Was the adverse reaction entered into Riskman? if yes, state the Riskman incident number

  YES

  NO

  N/A

• 7.13 Was the adverse reaction recorded in the patient's notes?

  YES

  NO

  N/A

Standard 8 - Prevebting and Managing Pressure Injuries

• 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

  Yes

  No

  N/A

• 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

  YES

  NO

  N/A

• 8.3 Can the patient independently reposition themselves?

  Yes

  No

  N/A

• 8.4 Is there a documented pressure injury prevention plan in the patient's progress notes?

  Yes

  No

  N/A

• 8.5 Has the pressure injury prevention plan been developed in partnership with patient and carers? (Check the patient notes)

  Yes

  No

  N/A

• 8.6 Select the preventative strategies being implemented for patients identified AT RISK of developing a pressure injury? You may select more than one.

  Select daily skin assessments recording patient skin condition malnutrition risk assessment protective padding repositioning regime reduce exposure to moisture

  • 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?

  Yes

  No

  N/A

• 8.8 What pressure reducing/relieving device(s) are being used for this patient? You may select more than one device.

  Select comfort/adjunct devices static cushions dynamic cushions static overlays dynamic overlays air matresses speciality bed heel aids

  • 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?

  YES

  NO

  N/A

• 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.

  YES

  NO

  N/A

• 8.11 Was an entry in RiskMan entered for any hospital acquired or worsening of pressure injury present on admission?

  YES

  NO

  N/A

• 8.12 Was the patient assessed as being “at risk of pressure injury”, given any written information on pressure injury? (ask patient)

  Yes

  No

  N/A

• 8.13 Was the patient’s weight recorded on admission?

  Yes

  No

  N/A

• 8.14 If the length of stay is greater than 7 days, has a follow up weight been recorded for patients at risk?

  YES

  NO

  N/A

• 8.15 Was the patient screened for malnutrition risk on admission?

  Yes

  No

  N/A

• 8.16 If the patient is at risk of malnutrition, has a referral to a dietician been made?

  YES

  NO

  N/A

• 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?)

  YES

  NO

  N/A

Standard 9 - Recognising and Responding to Clinical Deterioration

• 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?)

  Yes

  No

  N/A

• 9.2 Is a Track and Trigger observation chart in use?

  Yes

  No

  N/A

• 9.3 What vital signs have been recorded graphically on the observation chart? You may select more than one.

  Select Respiratory rate Oxygen saturation Heart rate Blood pressure Temperature Level of consciousness

  • Respiratory rate
  • Oxygen saturation
  • Heart rate
  • Blood pressure
  • Temperature
  • 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.

  Yes

  No

  N/A

• 9.5 Were core observations measured according to the minimum frequency specified in the monitoring plan or hospital policy for the last 24 hours?

  Yes

  No

  N/A

• 9.6 Were there any abnormal vital signs recorded in the last 24 hour period?

  Yes

  No

  N/A

• 9.7 If there are abnormal vital signs, is there evidence of escalation response as per actions required on MR6.01 EWS Chart?

  YES

  NO

  N/A

• 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)

  Yes

  No

  N/A

Standard 10 - Preventing Falls and Harm from Falls

• 10.1 Was the patient screened for risk of falling using MR6.05 Falls Risk Assessment?

  Yes

  No

  N/A

• 10.2 Is there a documented multifactorial falls prevention plan of care which includes strategies to reduce the identified falls risks?

  Yes

  No

  N/A

• 10.3 Is there evidence that the falls prevention plan has been developed in partnership with patient and carers?

  Yes

  No

  N/A

• 10.4 Has care been provided according to the falls prevention plan?

  YES

  NO

  N/A

• 10.5 If a mobility aid is required, is it within reach of the patient?

  YES

  NO

  N/A

• 10.6 Is the nurse call system within reach of the patient?

  Yes

  No

  N/A

• 10.7 Can the patient demonstrate how to use the nurse call system? If no, state why.

  Yes

  No

  N/A

• 10.8 Has the patient had a fall since being in hospital? Ask patient/state details

  Yes

  No

  N/A

• 10.9 Was the fall documented in RiskMan? (If yes, state the RiskMan Incident Number)

  YES

  NO

  N/A

• 10.10 Was the fall documented in the patient’s notes?

  YES

  NO

  N/A

• 10.11 Were fall prevention strategies implemented to reduce risk of repeated fall?

  YES

  NO

  N/A

• 10.12 Is there evidence of a Falls Sticker in the progress notes with a relevant explanation and plan of action.

  YES

  NO

  N/A

• 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

  YES

  NO

  N/A

• 10.14 Is the patient’s environment free of fall or trip hazards? If no, state the hazard.

  Yes

  No

  N/A

• 10.15 Has the patient been given information on falls prevention? (ask the patient)

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A