NNI Nursing Documentation Audit

• Site conducted

  Good

  Fair

  Poor

  N/A

• Conducted on

  Select

• Prepared by

• Location
  Address
• Medication
  Address

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• Yes

  No

  N/A

• Yes

  No

  N/A

• Braden Scale=Pressure Injury Risk Assessment and SSKIN Bundle documented

  Yes

  No

  N/A

• Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in

  Yes

  No

  N/A

• Vital Signs timely documented

  Yes

  No

  N/A

• Patient contraptions (LDAs) assessed , bundle timely documented and completed

  Yes

  No

  N/A

• 24 hours Intake and Output documented

  Yes

  No

  N/A

• Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• Nursing Notes timely documented using the standard Nursing Handover template in Epic

  Yes

  No

  N/A

• Nursing Care Plan timely documented

  Yes

  No

  N/A

• Patient Goals documented on Admission

  Yes

  No

  N/A

• Patient and Family Education

  Yes

  No

  N/A

• Functional Screening done on Admission

  Yes

  No

  N/A

• Psychocial screening done on Admission

  Yes

  No

  N/A

• Patients preference list completed on admission

  Yes

  No

  N/A

• Shift Required documentation completed - zero dots in the metrics

  Yes

  No

  N/A