Performance Manager
Survey of Nursing Practice (OB & NICU)
  GA
  PMA
  DOL
  MR #
   
  PAIN & STRESS MANGEMENT  
  Question: Does staff utilize a variety of pain and stress interventions for patients that are at particular risk for under-treatment of pain and stress?  
  Information Sources: Written Documentation • Pain / Stress Flowsheet • Events / Procedure Flowsheet • Medication Flowsheet • MAR • Nursing notes  
  Basic Determinants of Pain / Stress Presence: • Behaviors (e.g. facial expressions, body movements, agitation, crying, vocalizations) • Physiologic measures (e.g. changes in BP, HR, RR, oxygenation ) • Proxy pain report (report of pain from individual close to patient e.g. parent, family, caregiver)  
 
Written Documentation Audit
 
 
Is pain / stress assessed at each care interval?
Yes No
 
Are behavioral, environmental, and/or pharmacologic interventions documented when pain and/or stress is indicated?
Yes No
 
Is pain / stress assessed with stressful / painful interventions?
Yes No
 
Is there a reassessment of pain and/or stress after a behavioral, environmental or pharmacological intervention?
Yes No
 
Comments:
   
  INFECTION - VASCULAR ACCESS  
  Question: Is there appropriate assessment, management, and documentation of peripheral IVs, PICCs and umbilical lines?  
  Information Sources: Written Documentation • Lines and Tubes Flowsheet • Lines and Tubes Assessment Flowsheet  
 
Written Documentation Audit
 
 
Is the assessment of the vascular access sites (including presence / absence of infiltration, phlebitis, omphalitis) documented every hour?
Yes No N/A
 
Is the infusion status of the vascular access site documented consistently?
Yes No N/A
 
Observation and Written Documentation Audit
 
 
Is the location patient’s vascular access site accurately documented in the medical record?
Yes No N/A
 
Does the appearance of the PICC dressing concur with the written documentation?
Yes No N/A
 
Comments:
   
  SKIN INTEGRITY  
  Question: Are specific skin care interventions documented?  
  Information Sources: • Physical Assessment Flowsheet • Issues List • Nursing notes  
 
Written Documentation Audit
 
 
Is the patient’s position change documented with each set of cares?
Yes No
 
Is a skin care Issue identified?
Yes No
 
If yes, is there documentation of a skin care plan?
Yes No
 
Comments:
   
  ACTIVITY  
  Question: Is the level of activity appropriate to the physiologic stability and developmental age of the patient?  
  Information Sources: • Family Flowsheet • Developmental Care form • Issues List • Nursing notes  
 
Written Documentation Audit
 
 
If physiologically stable, does this infant have documentation of being held at least once each day?
Yes No N/A
 
Does this patient have an order for a developmental care visit?
Yes No N/A
 
For patients who are nearing term gestation, is their out of bed activity documented?
Yes No N/A
 
If “yes” which discipline documented this?
RN PCA OT/PT
 
Comments:
   
  PARENT EDUCATION  
  Question: Does documentation of parent education include assessment of parent’s learning needs, teaching content and method, and the parent’s response to teaching?  
  Information Sources: • Family Flowsheet • Discharge Instructions form • Nursing notes  
 
Written Documentation Audit
 
 
Are the parent’s learning needs identified?
Yes No
 
Is the individual receiving education identified (e.g.Mother, Father, other family member)?
Yes No
 
Was the teaching method was identified?
Yes No
 
Was the teaching content identified?
Yes No
 
Was the parent’s comprehension of the teaching assessed?
Yes No
 
Was the need for continued teaching addressed?
Yes No
 
Comments:
   
  CARE COMMUNICATION  
  Question: Is there documentation of communication with multi-disciplinary care team members?  
  Information Sources: • Issues List • Nursing note  
 
Written Documentation Audit
 
 
Is there a plan of care that corresponds to active Issues?
Yes
No
 
If yes, is it a problem focused note?
Yes No N/A
 
Comments:
   
  FEEDING PLAN  
  Question: Is the oral feeding plan defined?  
  Information Source: • Feeding form  
 
Written Documentation Audit
 
 
Is the oral feeding form filled in with the nipple and bottle used?
Yes No
 
Is the infant’s tolerance to feeding documented?
Yes No
 
Is the feeding method consistent between shifts?
Yes No
 
Comments:
   
  DISCHARGE PLANNING  
  Question: Is discharge teaching begun at least 2 weeks prior to potential discharge?  
  Information Source: • Discharge Instructions form  
 
Written Documentation Audit
 
 
Is there information on teaching activities when the infant is about 33 weeks gestation?
Yes No N/A
 
Infant’s current GA:
 
Comments:
   
  COMMUNICATION DURING HANDOFFS  
  Question: How often is a standard report format used during nurse to nurse shift report?  
 
Observation Audit
 
 
Is the nurse giving report using a developed report sheet?
Yes No
 
Does the receiving nurse have to request information after report is given?
Yes No
 
Does the receiving nurse indicate that the report wasn’t complete?
Yes No
 
Comments:
          



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