Large or Patient # Head of bed Patient Multiple Stuffed Patient Patient Caregiver Positioning Fluffy Flat? Asleep Blankets Animals in Nest Swaddled? asleep with Device Blankets Supine? to Crib? in Crib? baby? used? Around Pt.? Y or Degree Y or N of elevation Y or N Y or N Y or N Y or N Y or N Y or N Y or N 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Y Yes N- No –
Patient # Head of bed Flat? Y or Degree of elevation Patient Asleep Supine? Y or N Multiple Blankets to Crib? Y or N Stuffed Animals in Crib? Y or N Large or Fluffy Blankets Around Pt.? Y or N Patient in Nest Y or N Patient Swaddled? Y or N Caregiver asleep with baby? Y or N Positioning Device used? Y or N 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Y – Yes N- No
C4K-Audit-Form.docx