Nursing units

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Nursing Documentation

• Do all informed consents include the name of the specific procedure / treatment?

  Yes

  No

  N/A

• Do all informed consents include the signature of the patient?

  Yes

  No

  N/A

• Date and time signed?

  Yes

  No

  N/A

• Blood transfusion consent - is it informed consent obtained by the physician?

  Yes

  No

  N/A

• Are the pt's cultural and religious beliefs addressed in the education assessment?

  Yes

  No

  N/A

• Desire and motivation to learn?

  Yes

  No

  N/A

• Does the reason for admission match the documented education ?

  Yes

  No

  N/A

• If pt on vent, is there documentation of education by nursing or respiratory?

  Yes

  No

  N/A

• If stat med order does documented time given meet timeframe of stat?

  Yes

  No

  N/A

• Is the H&P completed within 24 hrs?

  Yes

  No

  N/A

• If use of protocol, is there an order for that protocol?

  Yes

  No

  N/A

• In reviewing plan of care, are pt's top 3 problems addressed?

  Yes

  No

  N/A

• Are multiple meds ordered for same reason such as pain?

  Yes

  No

  N/A

• Are pain reassessments for IV meds documented within the hour?

  Yes

  No

  N/A

• Are other pain reassessments completed within the required timeframe?

  Yes

  No

  N/A

• Do PRN meds have indications why ordered ?

  Yes

  No

  N/A

• Review plan of care. Are the assigned designations appropriate- A for active, D for discharge, C for completed?

  Yes

  No

  N/A

Staff Interviews

• What is the process for f/u when a pt does not provide a copy of their advance directive and how is that documented?

  Yes

  No

  N/A

• What would you do for a pt who doesn't speak English?

  Yes

  No

  N/A

• Can the staff person show how they can access the record to see what other disciplines are doing with the pt?

  Yes

  No

  N/A

• Can staff explain the process for insulin expiration? (Should be 28 days after opening vial. Rex writes the expiration date if insulin being used right away. If not, nursing writes the date)

  Yes

  No

  N/A

• What is the process for disposal of duragesic patches? ( must be witnessed by another nurse)

  Yes

  No

  N/A

• What is your unit doing for performance improvement?

  Yes

  No

  N/A

• How would you determine if a physician has privileges?

  Yes

  No

  N/A

Unit Observations

• Are crash cart checks done daily?

  Yes

  No

  N/A

• Is the lock number documented.

  Yes

  No

  N/A

• Are staff following correct procedures with isolation rooms?

  Yes

  No

  N/A

• Are temps checked as required on med refrigerators?

  Yes

  No

  N/A

• Is any equipment standing in same place in hallway for greater than 30 min?

  Yes

  No

  N/A

• Are sterile supplies being stored in shipping containers or cardboard boxes?

  Yes

  No

  N/A

• Are there any expired meds, normal saline, etc?

  Yes

  No

  N/A

• Are there nays opened vials with expiration beyond the 28 days?

  Yes

  No

  N/A

• Are there any unsecured meds in public areas?

  Yes

  No

  N/A

• Are there any expired supplies?

  Yes

  No

  N/A

• Are there any issues with clean equipment?

  Yes

  No

  N/A

• Is there any food and drink in the nurses station?

  Yes

  No

  N/A

• Was there evidence of any staff OTC meds found on unit such as break rooms?

  Yes

  No

  N/A

• Are the accucheck vials dated appropriately?

  Yes

  No

  N/A