Title Page
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Location
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Conducted on
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Prepared by
NNI Documentation Audit
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Braden Scale=Pressure Injury Risk Assessment and SSKIN Bundle documented
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Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in
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Vital Signs timely documented
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Patient contraptions (LDAs) assessed , bundle timely documented and completed
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24 hours Intake and Output documented
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Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented
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Initial patient assessment (V/S, GCS, Risk Assessment Screening) timely documented (within two (2) hours from commencement of the shift and completed within 4 hours
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Nursing Notes timely documented using the standard Nursing Handover template in Epic
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Nursing Care Plan timely documented
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Patient Goals documented on Admission
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Patient and Family Education
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Functional Screening done on Admission
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Psychocial screening done on Admission
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Patients preference list completed on admission
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Shift Required documentation completed - zero dots in the metrics
