Spectrum Health BR/RC Medical Record Audit

• Hotel

• Room #

• Housekeeper/Inspected by

• Conducted on

  Date
• Location
  Address

Chart Review

• All medical documentation is dated

  Yes

  No

  N/A

• All medical documentation is timed

  Yes

  No

  N/A

• History and physical fully completed

  Yes

  No

  N/A

• History and physical updated if done prior to admission

  Yes

  No

  N/A

• Does the history contain "inventory by body system" (review of systems)

  Yes

  No

  N/A

• Does the history contain the "chief complaint"

  Yes

  No

  N/A

• If H&P older than 24 hrs, but less than 30 days, is there a 24-hr update completed, signed and dated? Or an admitting note in progress notes to update recent events

  Yes

  No

  N/A

• Verbal Order/Telephone Order read back initiated

  Yes

  No

  N/A

• Verbal Order/Telephone Order authenticated

  Yes

  No

  N/A

• Approved abbreviations utilized

  Yes

  No

  N/A

• Nursing assessment complete ED & Outpt records, complete last section)

  Yes

  No

  N/A

• Pain assessed and reassessed

  Yes

  No

  N/A

• Restraints documentation completed HCP order)

  Yes

  No

  N/A

• Restraints documentation completed (RN initial assessment)

  Yes

  No

  N/A

• Restraints documentation completed (RN ongoing evaluations)

  Yes

  No

  N/A

• Is there a specific restraint order sheet correctly signed

  Yes

  No

  N/A

• Is there an individual order for use of restraints

  Yes

  No

  N/A

• Is there a specific restraint order sheet correctly dated

  Yes

  No

  N/A

• Is there a specific restraint order sheet correctly timed

  Yes

  No

  N/A

• Is there evidence of medication reconciliation at transfer of care

  Yes

  No

  N/A

• A handwritten operative progress note is entered immediately post-op

  Yes

  No

  N/A

• Pre-anesthesia assessment is documented

  Yes

  No

  N/A

• Examination of the airway is documented

  Yes

  No

  N/A

• A plan for general anesthesia is developed

  Yes

  No

  N/A

• Patient is re-evaluated immediately prior to induction of anesthesia

  Yes

  No

  N/A

• Is there a completed education record

  Yes

  No

  N/A

• Time out in OR to ensure that procedure, side, and sight are correct (verbal consensus)

  Yes

  No

  N/A

• Is there a completed plan of care

  Yes

  No

  N/A

• Was advanced directive question asked

  Yes

  No

  N/A

• Advanced Directive in chart

  Yes

  No

  N/A

• Informed invasive procedure consent obtained

  Yes

  No

  N/A

• Before informed consent is obtained, the risks, benefits, and potential complications are discussed by surgeon

  Yes

  No

  N/A

• Is there a specific procedural consent correctly signed in the chart

  Yes

  No

  N/A

• Is there a specific procedural consent correctly dated in the chart

  Yes

  No

  N/A

• Is there a specific procedural consent correctly timed in the chart

  Yes

  No

  N/A

• Is there a reason for blood transfusion

  Yes

  No

  N/A

• Is there a signed consent for blood transfusion

  Yes

  No

  N/A

• Blood administration documentation completed

  Yes

  No

  N/A

• The disclaimer statement is signed/dated by the attending surgeon (find an operative permit

  Yes

  No

  N/A

• Braden Risk assessment (skin) within 12 hours of admission

  Yes

  No

  N/A

• Medicare form is signed/dated when appropriate

  Yes

  No

  N/A

• Fall risk assessment is completed

  Yes

  No

  N/A

• General consent for treatment is signed

  Yes

  No

  N/A

• General consent for treatment meant is dated

  Yes

  No

  N/A

Medical Record Documentation

• Initial nursing assessment completed

  Yes

  No

  N/A

• Vital signs taken every 2 hours

  Yes

  No

  N/A

• Focused reassessment completed (pain, resp, cardio, neuro, psych)

  Yes

  No

  N/A

• Pain documentation completed

  Yes

  No

  N/A

• Restraint documentation completed

  Yes

  No

  N/A

• Influenza vaccine documentation completed (Sept. 23-March 31st)

  Yes

  No

  N/A

• Pneumococcal vaccine documentation completed

  Yes

  No

  N/A

Marketing material

• Guest directory

  Yes

  No

  N/A

• Report card on experience

  Yes

  No

  N/A

• Tourist brochures

  Yes

  No

  N/A

• Hotel food and drink menu

  Yes

  No

  N/A

Night table/desk

• 1 bible

  Yes

  No

  N/A

• 1 pocket folder with 3 envelopes

  Yes

  No

  N/A

• 1 am/fm clock

  Yes

  No

  N/A

Closet

• 3 hangers + 3 hangers with skirt clips

  Yes

  No

  N/A

General

• 1 ice bucket & poly liner

  Yes

  No

  N/A

• 1 waste basket

  Yes

  No

  N/A

• 3 ashtrays in guest room

  Yes

  No

  N/A

• 1 memo pad with hotel pen

  Yes

  No

  N/A

• 3 glasses

  Yes

  No

  N/A

• 1 telephone book

  Yes

  No

  N/A

Bathroom

• 1 frosted oval display tray

  Yes

  No

  N/A

• 2 bars of soap (1.25 oz)

  Yes

  No

  N/A

• 1 bottle of shampoo 22ml

  Yes

  No

  N/A

• 3 bath towels

  Yes

  No

  N/A

• 3 face cloths

  Yes

  No

  N/A

• 1 bath mat

  Yes

  No

  N/A

• Hairdryer

  Yes

  No

  N/A

• 2 toilet rolls

  Yes

  No

  N/A

Misc

• 1 coffee maker

  Yes

  No

  N/A

• 1 filter pack coffee

  Yes

  No

  N/A

• 1 filter pack decaffeinated

  Yes

  No

  N/A

• 1 tea bag

  Yes

  No

  N/A

• 1 condiment package

  Yes

  No

  N/A

• 1 iron

  Yes

  No

  N/A

• 1 ironing board

  Yes

  No

  N/A

• 1 fridge

  Yes

  No

  N/A

• 2 porcelain coffee cups

  Yes

  No

  N/A

Room

• Lights off

  Yes

  No

  N/A

• Heating set at 18 degrees or 70F

  Yes

  No

  N/A

• Windows closed

  Yes

  No

  N/A

• Television off with remotes out

  Yes

  No

  N/A

Bathroom

• Sinks off

  Yes

  No

  N/A

• Drain plugs open

  Yes

  No

  N/A

• Shower curtain centres

  Yes

  No

  N/A

• Shower head pointing towards wall

  Yes

  No

  N/A

• Toilet lid down

  Yes

  No

  N/A

• Bathroom door open

  Yes

  No

  N/A

• Light off

  Yes

  No

  N/A