Dialysis - Patient Documentation & Observation Tool Data Definition Tool
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Dialysis - Patient Documentation & Observation Tool Data Definition Tool This audit is to be completed by the manager or designee on a monthly basis. "Dialysis - Patient Documentation & Observation Tool" audits are due by the last day of the month. Instructions: Indicate Yes, No, NA (Not Applicable) for each question below. Submit 1 "Dialysis - Patient Documentation & Observation Tool" audit per month using the "Dialysis - Patient Documentation & Observation Tool" audit tool. Updated: 3/01/2016 QUESTION STANDARD LOCATION YES TRACERS - ADMISSION 1 Date of Observation 2 Medical Record # 3 Nursing physical assessment completed on admission. PC.01.02.01 EP 4; PC.01.02.03 EP 6 4 Functional screen complete. PC.01.02.01, EP 4; PC.01.02.03, EP 8 5 If functional screen positive, plans for follow-up documented. PC.01.02.01, EP 4 Patient hard chart Activities of Daily Living section completed. VMG Assesssment Positive screen follow up & Follow-up for documented on form; or Positive Intake negative screen = NA Screen in clinic intake form and or initial CIA and POC VMG Clinic Intake Nutritional screen completed. Form and or CIA or POC in hard chart 6 Nutritional screen complete. PC.01.02.01, EP 4; PC.01.02.03, EP 7 (Outpatient Only) If nutritional screen positive, plans for follow-up PC.01.02.01 EP 4; PC.01.02.03 EP 7 7 documented. VMG Clinic Intake Positive screen follow up Form and or CIA or documented on form ; or POC in hard chart negative screen = NA VMG Clinic Intake Pain screen completed Form and or CIA or POC in hard chart 8 Pain screen complete. PC.01.02.07, EP 1 & 2 VMG Clinic Intake Positive screen (option C and Form and or CIA or >3) follow up documented on POC in hard chart form; or negative screen = NA 9 If pain screen positive, plans for follow-up documented. PC.01.02.01, EP 23; PC.01.02.07, EP 3 VMG Clinic Intake Social Environment screen Form and or CIA or completed. POC in hard chart 10 Abuse screen complete. PC.01.02.09, EP 4 VMG Assesssment Positive screen follow up & Follow-up for documented on form; or Postive Intake negative screen = NA Screen. 11 If abuse screen positive, plans for follow-up documented. PC.01.02.09, EP 5, 6 & 7 12 Falls screen complete. PC.01.02.08 EP 1 13 If falls screen positive, plans for follow-up documented. PC.01.02.08 EP 2 Learning needs/education screen complete. 14 NA is inappropriate answer for inpatients. PC.02.03.01 EP 1, 4, 5 & 25 (Outpatient Only) If education screen positive, plans for follow-up 15 documented. Preferred language for discussing health care documented. 16 PC.02.01.21, EP 1 VMG Assessment & Follow-up. VMG Assessment & Follow-up. VMG Clinic Intake Form and or CIA/POC VMG Assessment & Follow-up and or CIA/POC Falls screen completed for pts >/= 65 yrs. Positive screen follow-up documented on form. Educational screen completed. VMG Clinic Intake Form and the Starpanel outpatient white board. CIA/POC Documented Positive screen follow-up documented on form or negative screen = NA PC.02.03.01 EP 10, EP 25 PC.02.01.21, EP 1 TRACERS - OPERATIVE & OTHER PROCEDURES 17 Consent form present and signed, dated and timed. RI.01.03.01 EP 13 Provider history and physical (H&P) completed and documented prior to procedure. (May use previous H&P documented within 30 days prior or 24 hours after admission or registration that includes an update. The update includes an examination and any changes to the patient's 18 condition.) PC.01.02.03 EP 5 Consent Form H& P form Form completed, signed, dated, and timed. H&P on record prior to procedure/surgery and w/in appropriate timeframes: TRACERS - MEDICATION ADMINISTRATION "Do Not Use" Abbreviations are NOT found in the MR on date of 19 service. No " Do Not Use" abbreviations are found in the medical record on the date of review. Physician orders, H&P, progress notes Diagnosis, condition or indications for use are documented. Physician orders in E Cube Medications list Order present. IM.02.02.01, EP 3 Supporting documentation (diagnosis, condition, or indication for 20 use) exists for every order for "current" medications. MM.04.01.01 EP 9 21 Order present for each medication administered. All entries in the medical record on date of review including medication orders, problem list, flowsheets, progress notes,etc. RC.02.01.01, EP 2 Are orders for PRN medications specific such that there is no Review patient's current PRN medication orders for therapeutic duplication. There should not be two orders that have the same instructions for when to administer (e.g., prn pain, prn nausea, prn for agitation). 22 therapeutic duplication (multiple options for a specific indication) TRACERS - PATIENT EDUCATION All "teaching/education" fields complete, as appropriate 23 (excluding pain management). Documentation by all disciplines involved in the patient's care, 24 treatment, or services. VMG Assesssment All teaching fields are & Follow-up for completed as appropriate. Positive Intake Screen and or patient education form in hard chart PC.02.03.01, EP 10, EP 25 Same as above. Signature(s) & initials are Paper and individual present for appropriate discipline notes disciplines. PC.02.03.01, EP 5 TRACERS - PROBLEM LIST (OP ONLY) 25 Complete (diagnoses, procedures, allergies, meds)? RC.02.01.07 EP 2 StarPanel - click on All component fields are Problem list. completed in StarPanel. StarPanel - click on Date of problem list matches Problem list.And or most current physician visit. in Ecube 26 Updated at every physician visit? RC.02.01.07 EP 3 DIALYSIS - CENTRAL VENOUS CATHETER EXIT SITE CARE WITH CHLORHEXEDINE OR ANTISEPTIC 27 Date of Observation 28 Staff Observed 29 Was a new tray/cart used? observed at chairside 30 Was hand hygiene performed before putting on gloves? observed at chairside 31 Were clean gloves put on before removing the old CVC dressing? observed at chairside Were gown, protective eyewear and mask or faceshield worn 32 during CVC exit site care? observed at chairside 33 Was a mask placed on the patient covering the nose and mouth? observed at chairside 34 Was the old CVC dressing removed and properly discarded? observed at chairside 35 Was the CVC exit site examined for signs of infection? observed at chairside If there was evidence of CVC exit site infection, was the team 36 leader notified? observed at chairside Hand hygiene was performed before putting on gloves Clean gloves were put on before removing the old CVC dressing Gown, protective eyewear and mask or faceshield was worn during CVC exit site care A mask was placed on the patient covering the nose and mouth The old CVC dressing was removed and properly discarded The CVC exit site was examined for signs of infection The team leader was notified of the evidence of CVC exit site infection observed at chairside Gloves were removed and hand hygiene performed after the CVC exit site was examined for infection Were gloves removed and hand hygiene performed after the CVC 37 exit site was examined for infection? A new tray/cart was used 38 Were clean gloves put on before cleaning the CVC exit site? observed at chairside Was the area around the CVC exit site cleaned with Chlorhexadine or antiseptic using a back and forth motion and beginning at the 39 exit site and working outward toward the periphery? observed at chairside Was the Chlorhexadine or antiseptic allowed to dry before 40 applying the clean dressing? observed at chairside Was hand hygiene performed after CVC exit site care was 41 complete? observed at chairside 42 Was a new sterile dressing applied to the CVC exit site? observed at chairside Were gloves removed following completion of the CVC exit site 43 care? observed at chairside Clean gloves were put on before cleaning the CVC exit site The area around the CVC exit site was cleaned with Chlorhexadine or antiseptic using a back and forth motion and beginning at the exit site and working outward toward the periphery Chlorhexadine or antiseptic was allowed to dry before applying the clean dressing Hand hygiene was performed after CVC exit site care was complete A new sterile dressing applied to the CVC exit site Gloves were removed following completion of the CVC exit site care DIALYSIS - INITIATION OF DIALYSIS WITH A CENTRAL VENOUS CATHETER 44 Date of Observation 45 Staff Observed 46 Was a new tray/cart used? observed at chairside 47 Was hand hygiene performed before putting on gloves? observed at chairside Were clean gloves put on before beginning the CVC initiation 48 procedure? observed at chairside 49 Was a mask placed on the patient covering the nose and mouth? observed at chairside Were gown, protective eyewear and mask, or faceshield worn 50 during the CVC initiation procedure? 51 Was a clean field placed under the CVC ports? 52 Were the catheter clamps closed? observed at chairside observed at chairside observed at chairside Were the CVC connections disinfected by scrubbing the hub 53 thread for 15 seconds with an alcohol pad and allowed to dry? observed at chairside Were sterile syringes connected to each port with aseptic 54 technique? observed at chairside 55 Was each port aspirated and/or flushed with sterile saline? observed at chairside A new tray/cart was used Hand hygiene was performed before putting on gloves Clean gloves were put on before beginning the CVC initiation procedure A mask was placed on the patient covering the nose and mouth Gown, protective eyewer and mask, or faceshield was worn during the CVC initiation procedure A clean field was placed under the CVC ports The catheter clamps were closed The CVC connections were disinfected by scrubbing the hub thread for 15 seconds with an alcohol pad and allowed to dry Sterile syringes were connected to each port with aseptic technique Each port was aspirated and/or flushed with sterile saline 56 Was treatment initiated successfully? 57 Were gloves removed following initiation? Was hand hygiene performed after the CVC initiation procedure 58 was complete? observed at chairside observed at chairside Treatment was initiated successfully Gloves were removed following initiation observed at chairside Hand hygiene was performed after the CVC initiation procedure was complete DIALYSIS - DISCONTINUATION OF DIALYSIS WITH A CENTRAL VENOUS CATHETER 59 Date of Observation 60 Staff Observed 61 Was a new tray/cart used? observed at chairside 62 Was hand hygiene performed before putting on gloves? observed at chairside Were clean gloves put on before beginning the CVC dialysis 63 discontinuation procedure? observed at chairside 64 Was a mask placed on the patient covering the nose and mouth? observed at chairside Were gown, protective eyewear and mask or faceshield worn 65 during the CVC discontinuation procedure? 67 Was the extracorporeal circuit reinfused? observed at chairside observed at chairside observed at chairside 68 Were gloves removed following dialysis discontinuation? observed at chairside 69 Was hand hygiene performed before putting on new gloves? observed at chairside 70 Were clean gloves put on before disinfecting CVC connections? observed at chairside 66 Was a clean field placed under the CVC ports? A new tray/cart was used Hand hygiene was performed before putting on gloves Clean gloves were put on before beginning the CVC dialysis discontinuation procedure A mask was placed on the patient covering the nose and mouth Gown, protective eyewear and mask or faceshield was worn during the CVC discontinuation procedure A clean field was placed under the CVC ports The extracorporeal circuit was reinfused Gloves were removed following dialysis discontinuation Hand hygiene was performed before putting on new gloves Clean gloves were put on before disinfecting CVC connections 71 Were the catheter clamps closed? Were the CVC connections disinfected by scrubbing before removing AND by scrubbing the hub thread for 15 seconds with an 72 alcohol pad? observed at chairside The catheter clamps were closed observed at chairside The CVC connections were disinfected by scrubbing before removing AND by scrubbing the hub thread for 15 seconds with an alcohol pad Were the closed CVC connections disinfected by wiping the outside connecting surfaces with an alcohol pad before 73 disconnecting blood lines? observed at chairside 74 Were the blood lines disconnected using aseptic technique? observed at chairside Were sterile port caps applied post treatment using aseptic 75 technique? 76 Were unused supplies discarded? observed at chairside observed at chairside Were gloves removed immediately after completing 77 discontinuation procedure? observed at chairside 78 Was hand hygiene performed immediately after removing gloves? observed at chairside The closed CVC connections were disinfected by wiping the outside connecting surfaces with an alcohol pad before disconnecting blood lines The blood lines were disconnected using aseptic technique Sterile port caps were applied post treatment using aseptic technique Unused supplies were discarded Gloves were removed immediately after completing discontinuation procedure Hand hygiene was performed immediately after removing gloves DIALYSIS - INITIATION OF DIALYSIS WITH AN AVF OR AVG 79 Date of Observation 80 Staff Observed 82 Was the tape prepared in the clean area? observed at chairside observed at chairside Was the skin over the access washed with soap and water OR 83 antibacterial scrub? observed at chairside 84 Was the access examined and evaluated prior to cannulation? observed at chairside The skin over the access was washed with soap and water OR antibacterial scrub The access was examined and evaluated prior to cannulation observed at chairside observed at chairside Hand hygiene was performed before putting on gloves Clean gloves were put on before cannulation 81 Was a new tray/cart used? 85 Was hand hygiene performed before putting on gloves? 86 Were clean gloves put on before cannulation? Were gown, protective eyewear and mask or faceshield worn 87 during cannulation? observed at chairside Was antiseptic applied to skin over cannulation sites and allowed 88 to dry? observed at chairside Was skin NOT TOUCHED between antiseptic application and 89 cannulation? observed at chairside 90 Was antiseptic applied in a circular motion from inner to outer? observed at chairside A new tray/cart was used The tape was prepared in the clean area Gown, protective eyewear and mask or faceshield was worn during cannulation? Antiseptic was applied to skin over cannulation sites and allowed to dry Skin was NOT TOUCHED between antiseptic application and cannulation Antiseptic was applied in a circular motion from inner to outer 91 Were cannulation needles inserted aseptically? 92 Were needles taped in place properly? observed at chairside observed at chairside 94 Were gloves removed following initiation? observed at chairside observed at chairside Was hand hygiene performed after initiation of dialysis with AVF 95 or AVG was complete? observed at chairside 93 Was treatment initiated with aseptic connection to blood lines? Cannulation needles were inserted aseptically Needles were taped in place properly Treatment was initiated with aseptic connection to blood lines Gloves were removed following initiation Hand hygiene was performed after initiation of dialysis with AVF or AVG was complete DIALYSIS - DISCONTINUATION OF DIALYSIS WITH AVF OR AVG, TO BE DONE DURING TREATMENT 96 Date of Observation 97 Staff Observed 98 Was a new tray/cart used? 99 Was the tape prepared in the clean area? observed at chairside observed at chairside A new tray/cart was used The tape was prepared in the clean area 100 Was hand hygiene performed before putting on gloves? observed at chairside Were clean gloves put on before starting the dialysis 101 discontinuation? observed at chairside Were gown, protective eyewear and mask or faceshield worn 102 during discontinuation? 104 Were the bloodlines properly disconnected? observed at chairside observed at chairside observed at chairside 105 Were gloves removed following dialysis discontinuation? observed at chairside Gown, protective eyewear and mask or faceshield were worn during discontinuation The extracorporeal circuit was reinfused The bloodlines were properly disconnected Gloves were removed following dialysis discontinuation observed at chairside observed at chairside observed at chairside observed at chairside Hand hygiene was performed before putting on new gloves Clean gloves were put on before removing needles Needles were removed with aseptic technique Needles were discarded in the sharps container 103 Was the extracorporeal circuit reinfused? 106 Was hand hygiene performed before putting on new gloves? 107 Were clean gloves put on before removing needles? 108 Were needles removed with aseptic technique? 109 Were needles discarded in the sharps container? Hand hygiene was performed before putting on gloves Clean gloves were put on before starting the dialysis discontinuation 110 Were needle sites held with clean gauze using clean gloved hands? DIALYSIS - DISCONTINUATION OF DIALYSIS WITH AN AVF OR AVG, AFTER HEMOSTASIS IS ACHIEVED 111 Date of Observation 112 Staff Observed 113 Was hand hygiene performed? 114 Were clean gloves put on? observed at chairside observed at chairside observed at chairside 116 Were unused supplies discarded? observed at chairside observed at chairside Were gloves removed immediately after completing 117 discontinuation procedure? observed at chairside 115 Were needle sites covered with a clean, dry bandage? 118 Was hand hygiene performed immediately after removing gloves? DIALYSIS - PATIENT TREATMENT AUDIT 119 Date of Observation 120 Staff Observed observed at chairside Does the machine prescribed treatment match the treatment 121 order: Dialyzer matches? observed at chairside Does the machine prescribed treatment match the treatment 122 order: BFR matches? observed at chairside Needle sites were held with clean gauze using clean gloved hands Hand hygiene was performed Clean gloves were put on Needle sites were covered with a clean, dry bandage Unused supplies were discarded The gloves were removed immediately after completing discontinuation procedure Hand hygiene was performed immediately after removing gloves The machine prescribed treatment match the treatment order: Dialyzer matches The machine prescribed treatment match the treatment order: BFR matches The machine prescribed treatment match the treatment order: DFR matches The machine prescribed treatment match the treatment order: Dialysate matches Does the machine prescribed treatment match the treatment 123 order: DFR matches? observed at chairside Does the machine prescribed treatment match the treatment 124 order: Dialysate matches? observed at chairside Are Vital Signs and safety checks being performed AT LEAST every 125 30 minutes? Vital Signs and safety checks documented on are being performed AT chairside flowsheet LEAST every 30 minutes If the patient has a catheter, was the Hemosafe Connector applied 127 correctly? documented on Patient evaluation was chairside flowsheet performed pre treatment The Hemosafe connector was observed at applied correctly to a chairside patients catheter Patient has bloodlines, access, and face uncovered during the 128 treatment? observed at chairside 129 Machine alarms are answered and resolved immediately? observed at chairside The patient has bloodlines, access, and face uncovered during the treatment The machinge alarms are answered and resolved immediately 130 The wet machine transducer was changed immediately? observed at chairside The wet machine transducer was changed immediately observed at chairside There is visible evidence of dry or wet blood on the equipment or surfaces 126 Was a patient evaluation performed pre-treatment? Is there visible evidence of dry or wet blood on the equipment or 131 surfaces? DIALYSIS - POST TREATMENT PATIENT CARE AUDIT 132 Date of Observation 133 Staff Observed 134 Was a patient evaluation performed post-treatment? documented on Patient evaluation was chairside flowsheet performed post treatment If the patient had a change in condition during the treatment was 136 the RN notified? RN was notified if the patient documented on did NOT achieve prescribed chairside flowsheet treatment parameters Nurse notified of a change in documented on condition during the chairside flowsheet treatment If the patient had a change in condition during the treatment was 137 it documented? If the patient can stand, was a post-dialysis standing BP documented? 138 Patient change in condition documented on during the treatment was chairside flowsheet documented Post dialysis standing BP documented on documented on patient that chairside flowsheet can stand If the patient did NOT achieve prescribed treatment parameters 135 was the RN notified?
