Title Page
-
Location
-
Conducted on
-
Conducted by
Sample 1
-
MRN
-
Adult Nursing Assessment completed
-
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
-
Vital Signs timely documented
-
24 hours Intake and Output documented
-
Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented
-
Patient contraptions (LDAs) assessed , bundle timely documented and completed
-
Purposeful Rounding timely done and completed
-
Daily Cares Safety completed
-
Device Cares Completed
-
Braden Scale=Pressure Injury Risk Assessment documented and completed
-
SSKIN assessment completed
-
Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in Avatar)
-
Morse Fall Screening completed
-
Functional Screening done on Admission
-
Psychocial screening done on Admission
-
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
-
Patients preference list completed on admission
-
Shift Required documentation completed
-
Zero dots in Metrics (for this specific ) patient; Note: If metrics cannot be zeroed- justification must be entered timely in the metrics review
Sample 2
undefined
-
MRN
-
Adult Nursing Assessment completed
-
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
-
Vital Signs timely documented
-
24 hours Intake and Output documented
-
Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented
-
Patient contraptions (LDAs) assessed , bundle timely documented and completed
-
Purposeful Rounding timely done and completed
-
Daily Cares Safety completed
-
Device Cares Completed
-
Braden Scale=Pressure Injury Risk Assessment documented and completed
-
SSKIN assessment completed
-
Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in Avatar)
-
Morse Fall Screening completed
-
Functional Screening done on Admission
-
Psychocial screening done on Admission
-
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
-
Patients preference list completed on admission
-
Shift Required documentation completed
-
Zero dots in Metrics (for this specific ) patient; Note: If metrics cannot be zeroed- justification must be entered timely in the metrics review
Sample 3
-
MRN
-
Adult Nursing Assessment completed
-
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
-
Vital Signs timely documented
-
24 hours Intake and Output documented
-
Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented
-
Patient contraptions (LDAs) assessed , bundle timely documented and completed
-
Purposeful Rounding timely done and completed
-
Daily Cares Safety completed
-
Device Cares Completed
-
Braden Scale=Pressure Injury Risk Assessment documented and completed
-
SSKIN assessment completed
-
Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in Avatar)
-
Morse Fall Screening completed
-
Functional Screening done on Admission
-
Psychocial screening done on Admission
-
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
-
Patients preference list completed on admission
-
Shift Required documentation completed
-
Zero dots in Metrics (for this specific ) patient; Note: If metrics cannot be zeroed- justification must be entered timely in the metrics review
Sample 4
-
MRN
-
Adult Nursing Assessment completed
-
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
-
Vital Signs timely documented
-
24 hours Intake and Output documented
-
Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented
-
Patient contraptions (LDAs) assessed , bundle timely documented and completed
-
Purposeful Rounding timely done and completed
-
Daily Cares Safety completed
-
Device Cares Completed
-
Braden Scale=Pressure Injury Risk Assessment documented and completed
-
SSKIN assessment completed
-
Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in Avatar)
-
Morse Fall Screening completed
-
Functional Screening done on Admission
-
Psychocial screening done on Admission
-
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
-
Patients preference list completed on admission
-
Shift Required documentation completed
-
Zero dots in Metrics (for this specific ) patient; Note: If metrics cannot be zeroed- justification must be entered timely in the metrics review
Sample 5
-
MRN
-
Adult Nursing Assessment completed
-
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
-
Vital Signs timely documented
-
24 hours Intake and Output documented
-
Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented
-
Patient contraptions (LDAs) assessed , bundle timely documented and completed
-
Purposeful Rounding timely done and completed
-
Daily Cares Safety completed
-
Device Cares Completed
-
Braden Scale=Pressure Injury Risk Assessment documented and completed
-
SSKIN assessment completed
-
Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in Avatar)
-
Morse Fall Screening completed
-
Functional Screening done on Admission
-
Psychocial screening done on Admission
-
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
-
Patients preference list completed on admission
-
Shift Required documentation completed
undefined
-
Zero dots in Metrics (for this specific ) patient; Note: If metrics cannot be zeroed- justification must be entered timely in the metrics review