Questions asked during the Standard Standard N/A Follow-up Comments or Notes tracer exercise: Met Not Met needed Do all pages of paper chart have 2 patient identifiers? Make note of documents within the Are all entries dated, timed, signed with credentials? medical Is your patient wearing appropriate Check for ID, allergy, falls identification bands? Identify patient allergies? Was the medical H&P completed within 24 hours of admission? Can you identify the point of entry for the patient? ED, Critical Care Transport, Direct Admit, OR, Floor, PICU, Other Can you identify the patient's course of care, treatment and services provided Can you locate the interdisciplinary Does flowsheet documentation (POC Plan of Care? Are the goals flowsheet appropriate for the patient? Is the > interdisciplinary rounds -> summary) response to each component of the accurately reflect documentation in plan documented? daily progress note? Response documented in POC flowsheet -> outcome summary -> progress & outcome summary How are orders recorded, transmitted and documented for a patient? Patient profile completed within 8 hours of admission? Nursing assessment in A&I flowsheet; Admission assessment completed within 8 hours of admission as per evidence of MD assessment (ex: H&P initiated, RN doc that MD in to assess, policy? consult note, event note, etc.) How do you assess risks for suicide Admission risk screening or family violence? Can staff verbalize safety process if Clinical practice guideline on suicide patient is suicidal based on risk precautions screens? How do you assess the patient's Included in patient profile language of choice? Where is this documented? How do you manage a patient who Door signage (falls wheel), yellow is "HIGH" risk for falls? band, sticker on chart, yellow slippers, consider sitter, minimize clutter, side rails, clear paths, call bell w/in reach Has a Braden risk assessment been completed and documented daily?
Questions asked during the tracer exercise: Standard Met Standard Not Met N/A Follow-up needed Comments or Notes Do all pages of paper chart have 2 patient identifiers? Are all entries dated, timed, signed with credentials? Make note of documents within the medical Is your patient wearing appropriate identification bands? Check for ID, allergy, falls Identify patient allergies? Was the medical H&P completed within 24 hours of admission? Can you identify the point of entry for the patient? ED, Critical Care Transport, Direct Admit, OR, Floor, PICU, Other Can you identify the patient's course of care, treatment and services provided Can you locate the interdisciplinary Plan of Care? Are the goals appropriate for the patient? Is the response to each component of the plan documented? Does flowsheet documentation (POC flowsheet > interdisciplinary rounds -> summary) accurately reflect documentation in daily progress note? Response documented in POC flowsheet -> outcome summary -> progress & outcome summary How are orders recorded, transmitted and documented for a patient? Patient profile completed within 8 hours of admission? Admission assessment completed within 8 hours of admission as per policy? Nursing assessment in A&I flowsheet; evidence of MD assessment (ex: H&P initiated, RN doc that MD in to assess, consult note, event note, etc.) How do you assess risks for suicide or family violence? Admission risk screening Can staff verbalize safety process if patient is suicidal based on risk screens? Clinical practice guideline on suicide precautions How do you assess the patient's language of choice? Where is this documented? Included in patient profile How do you manage a patient who is "HIGH" risk for falls? Door signage (falls wheel), yellow band, sticker on chart, yellow slippers, consider sitter, minimize clutter, side rails, clear paths, call bell w/in reach Has a Braden risk assessment been completed and documented daily?