Performance Manager
Survey of Nursing Practice (L&D)
  Demographics of Unit
  Unit
  MR #
  1.) CARE COORDINATION:  
  Where is the plan of care documented?  
  (If patient on L&D >4hours after initial assessment progress note and plan should be written)  
  Audit: Written documentation  
 
Source--
 
 
Is there a plan of care?
Yes No
 
Where is it documented?
 
 
Initial nursing assessment
Yes No
 
Patient progress note
Yes No
 
Verbal discussion -
 
 
Team meeting
Yes No
   
  2.) NURSE SENSITIVE PATIENT OUTCOMES: Skin  
  Audit: Written documentation  
 
Is patient encouraged to be OOB ambulating prior to epidural? Placement
Yes No
 
Is patient encouraged to turn q2 hours once epidural is placed?
Yes No
 
Is skin assessed on antepartum patient on prolonged bedrest?
Yes No
 
Is skin assessed on post partum patient on bedrest with Magnesium?
Yes No
 
Is skin assessed on transfer from OR after C/S?
Yes No
 
If patient has potential or impaired skin integrity this is documented in nursing records and appropriate interventions taken?
Yes No
   
  3.) PAIN: (Nurses Note or Narrative, Flowsheet )  
  Audit: Written documentation  
 
Assessment of patients coping? (BP elevation, presence or absence of agitation)
Yes No
 
Are alternative pain control options offered and documented: Shower, ball, massage, rocking, nubaine, epidural, PCA
Yes No
 
Is pain/ coping assessed prior to and after intervention?
Yes No
   
  4.) Patient Education:  
  Re: labor/ pain management options, second stage anticipatory guidance, post partum care, and breastfeeding  
  Audit: Wrutten documentation  
 
Patient Teaching--
 
 
Labor/ pain management options
Yes No
 
Second stage anticipatory guidance
Yes No N/A
 
Post partum care
Yes No
 
Breastfeeding
Yes No N/A
 
Comprehension was assessed?
Yes No
 
Need for continued teaching was addressed
Yes No
   
  5.) INFECTION:  
  5a.) IV Sites  
  Audit: Written documentation, observation  
 
Are IV sites assessed q shift for infiltration and phlebitis?
Yes No
 
Do all IVs have date of insertion written on IV flow sheet?
Yes No
 
Are any peripheral IV sites on a unit older then 4 days old?
Yes No
  5b.) Foleys  
  Audit: Written documentation  
 
If foley in place is there an order?
Yes No N/A
 
Is date of insertion documented on flowsheet?
Yes No N/A
   
  6.) HANDOFFS  
  Audit: Observation  
 
Was there a verbal exchange?
Yes No
 
Did the nurse review the nursing flowsheet with oncoming nurse confirming completeness of documentation?
Yes No
 
Was there a verbal exchange of plan of care?
Yes No
  Audit: Written documentation  
 
Hand off documented on flow sheet?
Yes No
          



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