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

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  • 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

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  • Zero dots in Metrics (for this specific ) patient; Note: If metrics cannot be zeroed- justification must be entered timely in the metrics review

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