12-Hour Chart Check Audit Tool

United Medical Rehabilitation Hospital
 
 
 
Day Night
# Audit Element Yes No N/A
Orders & Medications
1 New orders have been reviewed for completeness.
2 All new MARs have been verified with the order.
3 All new medication orders have been added to the MAR.
4 All antibiotics ordered have a completed Infection Report Form on the chart.
11 All PRN medications have a documented response to medication.
12 All antihypertensive medications have parameters and are being followed. Physician notified if medication not given.
13 Medications not given have a documented reason on the MAR.
28 All blood transfusions appropriately documented.
Labs, Tests & Diagnostics
5 All labs ordered have been drawn and sent to the identified lab. Procedure documented in narrative summary and lab log updated.
6 Lab results are on the chart within the established time frame.
7 Physician consults have been completed and are on the chart.
8 All tests (X-rays, ECGs, etc.) have follow-up reports on the chart.
27 Verbal critical labs documented with physician notification and intervention (if applicable).
Vitals & Daily Monitoring
9 Vital signs, I&Os, and daily or weekly weights have been documented.
10 Daily weight documented for HD and cardiac patients.
19 Accu-checks documented as ordered.
Patient Care & Nursing Documentation
14 If patient is on a bowel or bladder program, care has been documented.
15 Patient's last bowel movement has been documented.
18 Nursing narrative completed each shift reflecting skilled nursing and rehab progression.
20 Provider documentation reviewed and physician contacted if orders do not match daily note.
21 If pressure ulcer present, assessment and interventions documented in medical record. Wound photographed and measured on admit and weekly.
Transfers & Incidents
16 Patients transferred during the shift have a completed Patient Transfer Form on the chart.
17 If a fall occurred, documentation is in the chart and Huddle Form sent to DON.
Admissions & Care Planning
22 All admission orders and assessments completed in timeframe.
23 IPOC initiated on admission and appropriate to patient condition.
24 4-Day IPOC completed timely.
25 3-Day GG codes completed.
26 Daily care plan reflects changes in patient condition.

Deficiencies Identified:

Corrective Action Taken: