Performance Manager
Survey of Nursing Practice (Med-Surg & CC)
  Demographics of Unit
  Unit
  MR #
   
  1.) NURSE SENSITIVE PATIENT OUTCOMES: confusion and delirium as important variables in patient falls.  
  Information Source: Nursing Notes  
  Question: Are nurses using appropriate confusion assessment variables?  
  Audit: Written Documentation  
 
Is the patient consistently alert and oriented?
Yes No
 
If "yes," proceed to the next section of survey.
 
 
If patient is not alert and oriented, is this their baseline?
Yes No Uncertain
 
Is presence of confusion documentated?
Yes No N/A
 
Is presence of fluctuating confusion documented?
Yes No N/A
 
Is acute onset of mental status changes notes?
Yes No
 
If "yes," was a trigger called? (check presence trigger note)
Yes No
 
Is altered LOC noted?
Yes No
 
Is a delirium problem noted by the RN?
Yes No
   
  2.) PAIN  
  Information Source: Nursing note, bedside flowsheets, MAR, kardex  
  Basic Measurements of Pain Intensity:  
  • Patient’s self report (numeric, simple descriptive, visual analogue, faces scales)  
  • Behaviors (e.g. facial expressions, body measurements, agitation, crying, vocalizations)  
  • Proxy pain report (report of pain from individual close to patient e.g. parent, spouse, family, caregiver)  
  • Physiologic measures (e.g. changes in BP, pulse, RR)  
  Question: Does staff utilize a variety of pain assessment tools/strategies for patients that are at particular risk for under-treatment of pain?  
  Audit: Written Documentation  
 
For those patients ABLE to provide a self-report of pain, proceed to next section of survey.
 
 
For those patients unable to provide a self-report of pain (r/t confusion, sedation, unconsciousness, or cognitive deficit) is pain assessed using other/multiple methods?
Yes No N/A
 
For those patients unable to provide self-report of pain, is the assessment method documented?
Yes No
 
Is the assessment method (e.g. presence of pain behaviors) used to reassess pain post-pharmacologic intervention?
Yes No
   
  3.) INFECTION  
  3a.) PERIPHERAL INTRAVENOUS ACCESS  
  Information Source: Nursing notes, bedside IV sheets, kardex  
  Question: Is there appropriate assessment, management, and documentation of peripheral IVs?  
  Audit: Written Documentation  
 
If this patient does not have a peripheral IV, skip to question 3b.
 
 
Is the assessment of peripheral IV site (including presence/absence of infiltration and phlebitis) documented every shift?
Yes No
 
If “yes”, where is this documented? (check all that apply)
 
 
Nursing Note
 
Kardex
 
Bedside Flowsheet
  Observation  
 
Does the patient’s peripheral IV have date of insertion written on the dressing?
Yes No
 
Is the peripheral IV site older then 4 days old? (note: any undated peripheral IV site is considered > 4 days old)
Yes No
   
  3b.) FOLEY CATHETERS  
  Information Source: Nursing notes, bedside IV sheets, kardex, POE alternative dashboard, H/P, intra-facility transfer notes  
  Indications for Foley catheters:  
  • Post-op requirement/surgical pathway  
  • Acute urinary retention/obstruction  
  • Patient requires close urine output monitoring  
  • Patient requires chronic catheterization/neurogenic bladder  
  • Urinary incontinence with open sacral/perineal wounds  
  • End of life/comfort care  
  Question: Is the indication, placement, and discontinuation of Foley catheters documented appropriately?  
  Observation  
 
Does this patient currently have a Foley catheter?
Yes No
  Audit: Written Documentation  
 
Does the patient have a Foley catheter? If no, skip to question #4.
 
 
Is there an indication for Foley catheter?
Yes No
 
Is there an order for insertion of Foley catheter?
Yes No
 
Is the insertion date of the Foley catheter documented?
Yes
No
 
If “yes”, where is this documented?
 
 
Nursing Note
 
Kardex
 
Bedside Flowsheet
 
Is there an order for the removal of the Foley catheter?
Yes No N/A
 
Is Foley catheter removal date documented?
Yes No N/A
 
If yes, where is this documented?
 
 
Nursing Note
 
Kardex
 
Bedside Flowsheet
 
Is the presence/absence of a Foley catheter indicated correctly on the POE alternative dashboard?
Yes No
   
  4.) NURSE SENSITIVE PATIENT OUTCOMES: Skin and Wound  
  Information Source: Nursing notes, bedside flow-sheets, kardex  
  Question: Are specific wound care interventions documented?  
  Audit: Written Documentation  
 
If patient is on bed-rest for a portion of the day, is there documentation of a turning schedule q1-2 hours?
Yes No Turns Independently
 
Do the nursing notes document that the HOB elevation is maintained at/or below 30 degrees?
Yes No
 
Is the skin moisture control plan identified?
Yes No
 
If the Braden score is 18 or less (or patient has potential for impaired skin integrity) was a nutritional consult ordered?
Yes No N/A
  Are adult diapers being used on this patient? Yes
No
   
  5.) NURSE SENSITIVE PATIENT OUTCOMES: Activity  
  Information Source: POE order, nursing notes, kardex  
  Question: Is an activity progression plan being implemented?  
  Audit: Written Documentation  
 
Does this patient have an activity order?
Yes No
 
For patients with a “non-bedrest” activity order, is there documentation that the patient was OOB today?
Yes No N/A
 
If “yes” which discipline documented this? (please mark all that apply)
 
  RN
 
PCT
 
PT
   
  6.) PATIENT EDUCATION  
  Information Source: Nursing notes, kardex  
  Question: Does documentation of patient education include assessment of patient learning needs, teaching content/method, and patient response to teaching?  
  Audit: Written Documentation  
 
Is assessment of patient learning needs identified?
Yes No
 
The individual receiving education was identified (e.g. patient, family, or other)?
Yes No
 
Was the teaching method was identified?
Yes No
 
Was the teaching content identified?
Yes No
 
Was patient comprehension of teaching assessed?
Yes No
 
Was the need for continued teaching addressed?
Yes No
   
  7.) CARE COORDINATION  
  Information Source: IPA/FHPA/ kardex, nursing note  
  Question: Is there documentation of communication with multi-disciplinary care team members?  
  Audit: Written Documentation  
 
Is there a plan of care for today?
Yes No
 
If yes, is it a problem focused note?
Yes No
 
Where is the nursing plan of care documented?
 
 
a.) New Audit
IPA FHPA
 
b.) Nursing Progress Note
Yes No
 
c.) Nursing Kardex (in handoff section)
Yes No
 
d.) Patient Whiteboard
Yes No
   
*Critical Care Only*  
  8.) How was the plan of care communicated?  
  Observation: nurse handoff verbal report, kardex / ICU update use  
 
Did the nurse review the nursing kardex/ ICU update?
Yes No
 
Was there a verbal exchange after review of the kardex, or reading the nurses note from prior 24 hours?
Yes No
 
Were the following verbally discussed in handoff?
 
 
activity
Yes No
 
ambulation
Yes No
 
safety
Yes No
 
skin
Yes No
 
education plan
Yes No
   
  9.) NURSE SENSITIVE PATIENT OUTCOMES: neuro/sedation/etoh withdrawal. Are nurses using appropriate assessment variables?  
  Audit: Written Documentation  
 
Is a Glascow Coma scale noted?
Yes No
 
Is a Riker scale completed?
Yes No
 
If ETOH/drug withdrawal noted; is a CIWA/CINA scale utilized?
Yes No N/A
   
  10.) RESTRAINTS  
  Audit: Written Documentation  
 
Is there documentation of least invasive measures implemented prior to restraint application?
Yes No
 
Is there a current order for active restraints?
Yes No
          



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