Performance Manager
Nursing Documentation Audit - November & April (through FY16)
  This Documentation Audit should be completed during November and April. No additional Documentation Audits need to be completed during these 2 months.  
   
  Review Month
  Review Year
  Review By
General Information Record Type (minimum:3 Open, 2 Closed per month) Open Closed
  Area or Unit
  Medical Record Number
Consents Is the General Agreement form present? Yes No
  *ICU ONLY Question* Is the ICU Consent form present and complete? Yes No N/A
  *ICU ONLY Question* Is procedure consent present and complete? Yes No N/A
Initial Pt Assessment Is the admitting diagnosis or chief complaint identified? Yes No N/A
  Was a need for an interpreter assessed? Yes No N/A
Healthcare Proxy If the patient does not have a Health Care Proxy, was information given to him/her? Yes No N/A
Neurological Assessment Was the patient's Mental Status/ Ability to Comprehend assessed? Yes No N/A
Functional Status Was the patient's need for assistance with ADL's assessed? Yes No N/A
  If the patient was determined to be at risk to fall or noted to have impaired functional status, was a referral made to Physical Therapy? (look in POE) Yes No N/A Note:ICU=n/a
Nutrition Was the patient's Nutritional status assessed? Yes No N/A
Care Plan Was patient's plan of care based on patient's goals and the timeframes, settings, and services required to meet those goals? Yes No
Timeliness Was the initial assessment completed within established policy timeline of admission to the floor? Yes No
   
Daily Note  
Neurological Was the Test of Attention documented? Yes No N/A
  If Yes to the above question, does it indicate which test was used? Yes No N/A
IV Assessment Was the IV insertion date documented? Yes No N/A
  Was the IV gauge documented? Yes No N/A
  Was the location of the IV documented? Yes No N/A
  Was the IV assessment completed? Yes No N/A
  If the IV was removed, was the reason documented? Yes No N/A
  Was the IV flush documented every shift for the past 24 hours? Yes No N/A
Fall Interventions Were ALL appropriate fall prevention interventions documented and in alignment with the patient's fall risk assessment? Yes No
Skin/Wound Was the patient's Braden Scale Score completed and documented? Yes No N/A
  **For patients with a Braden Score of 18 or less**: Was all required skin integrity information documented appropriately? Yes No N/A
  *ICU ONLY Question* Was a skin impairment assessment completed 1x per shift? Yes No N/A
  *ICU ONLY Question* Is patient's activity/position changed and documented every 2 hours? Yes No N/A
Medication Tolerance Was the patient's tolerance to medication documented? Yes No N/A
Teaching Was patient's teaching based on his/her assessed needs? Yes No
  Was it documented who was taught? (patient, family, other) Yes No N/A
  Was the patient's comprehension of all teachings evaluated and addressed? Yes No
  Were barriers to learning documented and addressed? Yes No
  Was patient provided with care, treatment, and services according to his/her individualized plan? Yes No
  Based on the goals established in patientís plan of care, staff evaluated the patientís progress? Yes No
  Over the course of patient's admission, where all teach back questions addressed? Yes No
  Was the patient's comprehension of all discharge teachings evaluated and addressed? Yes No N/A
Plan of Care in Note Is there documentation of the reassessment of the Plan of Care based upon the patient's response to interventions? Yes No N/A
  Does the documentation reflect the fact that different disciplines are involved and that the care is coordinated? Yes No
Signature/Date/Time Was the nursing note SIGNED? Yes No
  Was the nursing note DATED? Yes No
  Was the nursing note TIMED? Yes No
Transfers Patient/Family are notified of transfer? Yes No N/A
  Was the transfer note SIGNED? Yes No N/A
  Was the transfer note DATED? Yes No N/A
  Was the transfer note TIMED? Yes No N/A
Chart Review  
Telemetry (ICU- EKG) Was there documentation of 2-intitals indicating double identifiers at initiation of telemetry? Yes No N/A
  Was a telemetry strip printed on admission? Yes No N/A
  Was the telemetry documented in the shift note? Yes No N/A
  Was a daily telemetry strip present in chart? Yes No N/A
  Were the daily telemetry intervals measurements documented? Yes No N/A
  In reviewing the last 16 hours of telemetry, was a monitor check documented 8 times? Yes No N/A
  **For units with telemetry technicians only** In reviewing the last 16 hours of telemetry monitoring, is an RN cosignature present 4 times? Yes No N/A
  *ICU ONLY Question* Where alarms documented per shift? Yes No N/A
  *ICU ONLY Question* Do alarms match monitor in Meta Vision? Yes No N/A
  *ICU ONLY Question* Is pressure tracings charted per shift? Yes No N/A
Discharges/Previous 48hrs Is there evidence in the chart that the discharge plan was discussed with patient? Yes No N/A
  If indicated, does the discharge plan include follow-up appointment information, prescribed treatment and services? Yes No N/A
  Is information about how patient can obtain further care, treatment and services present? Yes No N/A
Discharge Pt Education **For discharged patients** Was all required discharge information given to the patient (see below)?  
  Safe/Effective Medical Equipment use? Yes No N/A
  Danger Signs? Yes No N/A
  Pain/Pain Management? Yes No N/A
  Is a signed copy of the discharge plan in the chart? Yes No N/A
Legibility & Abbreviation Approved Abbreviations Only in reviewed documents? Yes No
  Rate the overall legibility of the nuring notes.
Flowsheet  
Date Was the nursing flowsheet DATED on the 1st page? Yes No N/A
  Was the nursing flowsheet DATED on the 2nd and 3rd page? Yes No N/A
Dyspnea Was dyspnea assessed and documented according to policy? Yes No N/A
RASS/ Delirium Was the RASS scored and documented according to policy? Yes No N/A
  *ICU ONLY Question* Delirium/CAM Score is completed 1x per shift? Yes No N/A
Pain/Comfort Was pain assessed according to policy? Yes No
  If yes, what method was used to assess pain?
  In review of the last 16 hours, documentation indicates action taken to respond to pain? Yes No N/A
  In review of the last 16 hours, was the pain reassessed according to policy? Yes No N/A
  *ICU ONLY Question* RASS Score is completed 1x per shift? Yes No
Fall Risk Has the patient's fall risk assessed according to policy? Yes No
Oral Care Was the O-CAT Score completed within the last 24hours? *Not applicable if intubated Yes No N/A
  Was oral care documented on flowsheet? Yes No N/A
   
MAR  
VTE Was pharmacological prevention given as ordered during the last 3 days? Yes No N/A
  IF NO pharmacological prevention was given, was the reason the medication was held documented in the MAR? Yes No N/A
  IF NO pharmacological prevention was given, is there evidence in the medical record that the LIP was notified? Yes No N/A
Signature The MAR Signature Log was SIGNED by all RNs who administered medication, daily. (Initials should match signature log) Yes No N/A
Inpatient Psych ONLY  
Safety Tools Was the safety tool completed using feedback from the patient and/or family? (look for signature) Yes No
  Was the information that is required for Joint Commission documented on the Safety Tool? If Yes, skip to Social Work Assessment question. Yes No
  If something was NOT documented, please specify the topics that were NOT documented below (a-d).  
  a.) Techniques, methods or tools that would help the patient control his or her behavior
  b.) Pre-existing medical conditions or any physical disabilities that would place the patient at greater risk during restraint or seclusion
  c.) History of sexual or physical abuse that would place the patient at greater psychological risk during restraint or seclusion
  d.) Documentation that the patient was educated on the hospital's philosophy/policy on restraint and seclusion
Social Work Assessment Does the Social Work assessment have documentation of the community resources that the patient was using before admission Yes No N/A
Procedure Form Was the ECT procedure form completed for the previous 3 treatments? Yes No
   
ICU ONLY  
  Was an order in chart for all invasive lines? Yes No N/A
  Was an order in chart for NS flushes? Yes No N/A
  Was the physician note completed for each procedure? Yes No N/A
  Was the FHPA completed and signed per policy? Yes No N/A
  Was a CIWA/CINA score completed every 1-2 hours? Yes No N/A
          



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