Adherence to Orders - Patient Care Orders

DNV Finding - Medical Record Review (Review orders and flowsheet documentation for the last 2-3 shifts as applicable)

Which department are you completing this survey for?

Patient MRN?

VS: Are Vital Signs documented as per the order?

TPRBP Q (frequency)

Please list the noncompliant element(s) and the RN name(s).

Pulse Ox: Is Pulse Oximetry documented as per the order?

Ex: Continuous, spot check, etc.

Please list the noncompliant element(s) and the RN name(s).

Ex: Order for continuous pulse ox, documented only spot check.

O2: If the patient is on oxygen, is there an order for oxygen and does the documentation align with the ordered parameters?

Please list the noncompliant element(s) and the RN name(s).

Weight: Are weights documented as ordered?

Ex: Daily, weekly, in am, etc.

Please list the noncompliant element(s) and the RN name(s).

Ex: Missing daily weight on "xx" date.

I&O: Are I&Os documented as ordered?

Ex: Strict/accurate = document in "ml"

Ex: Strict output q4hrs

Please list the noncompliant element(s) and the RN name(s).

IS: Was incentive spirometer documented as ordered?

Ex: 10x/hr. while awake.

Ex: Q1 hr. while awake.

Please list the noncompliant element(s) and the RN name(s).

Ex: Missing documentation of IS in the flowsheet on "xx" date "xx" time.

SCD: Are SCDs (Sequential Compression Device) documented as ordered?

Please list the noncompliant element(s) and the RN name(s).

Ex: No documentation of SCD use on "xx" day.

Titration of Medications - Did nursing follow titration instructions?

Ex: Titrate down by "xx" every 2 hours to a goal of "TOF 2-3 out of 4." - Did nursing document TOF's? (Train-of-Four (TOF) Monitoring parameter located in Neuro section of flowsheet.)

Please list the noncompliant element(s) and the RN name(s).

Ex: TOF parameter not added to flowsheet. Ex: TOF parameter - no documentation. Ex: No titration goal identified in order.

Additional findings?