Nursing Department Chart Review Effectiveness 3Q2017 Saco Findings Compliance Indicators 13/15 87% Encounter note written between the hours of 0700-2300. 6/15 40% A shift assessment is completed each shift. 14/15 93% Weekly Summary note completed. Observational note completed on patient who is on a higher 6/15 93% level of observation i.e. ¼ hour checks or 1:1. 8 n/a Diabetes teaching checklist active/completed (if patient is 2/15 100% diabetic). 13 n/a Multidisciplinary Teaching checklist active/completed. 14/15 93% 15/15 100% Dental Education Teaching checklist active/completed. Nursing Assessment of Suicide Risk being completed with 15/15 100% Treatment Plan Review. Annual Assessment completed. 6/15 100% 9 n/a Patient’s Rights reviewed and signed. 12/15 100% 3 ref. Informed Consent signed, dated and timed. 12/15 100% 3 ref. Number of Telephone Orders for the month. 20/20 100% 20/20 100% Number of Telephone Orders signed by the prescriber within 24 hours.
Nursing Department Chart Review Effectiveness 3Q2017 Saco Indicators Findings Compliance Encounter note written between the hours of 0700-2300. 13/15 87% A shift assessment is completed each shift. 6/15 40% Weekly Summary note completed. 14/15 93% Observational note completed on patient who is on a higher level of observation i.e. ¼ hour checks or 1:1. 6/15 8 n/a 93% Diabetes teaching checklist active/completed (if patient is diabetic). 2/15 13 n/a 100% Multidisciplinary Teaching checklist active/completed. 14/15 93% Dental Education Teaching checklist active/completed. 15/15 100% Nursing Assessment of Suicide Risk being completed with Treatment Plan Review. 15/15 100% Annual Assessment completed. 6/15 9 n/a 100% Patient’s Rights reviewed and signed. 12/15 3 ref. 100% Informed Consent signed, dated and timed. 12/15 3 ref. 100% Number of Telephone Orders for the month. 20/20 100% Number of Telephone Orders signed by the prescriber within 24 hours. 20/20 100%
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