Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

NNI Documentation Audit

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

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

  • Vital Signs timely documented

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

  • 24 hours Intake and Output documented

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

  • 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

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

  • Nursing Care Plan timely documented

  • Patient Goals documented on Admission

  • Patient and Family Education

  • Functional Screening done on Admission

  • Psychocial screening done on Admission

  • Patients preference list completed on admission

  • Shift Required documentation completed - zero dots in the metrics

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