Clinical Documentation Audit (Long form) Date _________________RN completing audit__________________________ Nurse(s)/NCT Audited_______________________Patient Audited____________________

Patient Profile: Yes No N/A Comments:

Is patient profile complete?

Plan of care: Yes No N/A Comments:

CPG present?

Was plan of care individualized? *Individualize with patient specific information, don’t put goals here.

Patient Care Flowsheet: Yes No N/A Comments:

If patient on an intravenous drip, has the rate been documented per unit guidelines?

If patient on a drip, are there cosignatures documented with rate changes, at change of shift, or with a new bag hanging?

If ordered, were daily weights recorded?

Intake & Output: Yes No N/A Comments:

Was I&O recorded every 8 hours or as ordered? (RN information such as IV fluids, tube feedings, etc.)

Assessment and Intervention:(head to toe assessment q shift and prn changes) Pain/comfort

Was pain assessed per your unit assessment guidelines (q shift or q 4) and prn?

If pain goal was not met, was an intervention documented?

If any intervention documented was pain reassessed?

Safety

Fall Risk Documented? (BID, admission, and with significant change)

If fall risk level above 5, were specific fall prevention interventions documented?

Peripheral/Neurovascular

If ordered, are SCDs documented as intervention?

Clinical Documentation Audit (Long form) Date _________________RN completing audit__________________________ Nurse(s)/NCT Audited_______________________Patient Audited____________________

Access/Monitoring devices

If tubing change due, was it documented?

Respiratory

If patient is on ventilator or has a trach, was suctioning documented?

Nutrition

If patient on tube feedings, was further assessment documented? (residuals monitored, free water administered)

Musculoskeletal

Was current functional screen done on admission?

Was activity level documented in interventions?

Was ROM or ambulation charted?

Skin Yes No N/A Comments:

Was Braden score documented as per policy? (Sun, Tue, Thu, on admit, transfer, post-op)

Were wounds measured and documented per policy? (on admit and each Tuesday)

If score <18, was Pressure Ulcer Risk CPG added?

Was hygiene care documented? (oral care, bath, linen change, foley care)

Coping/Interventions

Plan of Care reviewed every shift?

Additional Information

Was POC related to CPG documented in the A&I prior to discharge?

If vaccine protocol ordered, was the order completed and administration documented?

Adult Education Outcome Record Yes No N/A Comments:

Were learning needs assessed on admission? (only required upon admission or with significant change)

Was initial teaching done on admission? (speak up, pain scale, room orientation, etc.)

Was teaching documented at least daily?

Was teaching related to CPG documented prior to discharge?

Was tobacco education given and documented (even for non-smokers)?

Clinical Documentation Audit (Long form) Date _________________RN completing audit__________________________ Nurse(s)/NCT Audited_______________________Patient Audited____________________

Was Quit line referral made and documented if appropriate? (N/A if non-smoker)

Goal/Outcome Record Yes No N/A Comments:

Were CPG's addressed when documenting on Goal/Outcome Evaluation?

Was shift outcome note documented?

Restraints (This entire section is N/A if patient not in restraints) Yes No N/A Comments:

Is there a restraint order present and current?

Is the date of restraint initiation documented?

Is the type(s) of restraint documented initially and every 12 hours?

Are alternatives attempted, documented initially and every 12 hours?

Is family education/agreement(s) documented?

Are every 1 hour assessments documented?

Are every 2 hour assessments documented?

Are every 4 hour assessments documented?

Discharge Yes No N/A Comments:

If patient was discharged from the hospital, was discharge note completed?

Paper Items Yes No N/A Comments:

Was medication reconciliation database completed?

Was A & A completed upon admission?

Personal Effects Sheet completed?

Original tool developed by Heather Wilson 7/3/08, Revised 01/29/09, 8/1/09, 7/1/10