PART I.

Patient No._ Patient No._

Name of Patient A.B
Sex F
Age 13
Date admitted 10-03-13
Discharge date 10-05-13
Name of institution iga !emoria" District #os$ita"
F"oor Surgica" %ard
!edica" Su$er&ision %ard
'om$"ete Diagnosis (herma" Burn) Face and Pa"m
Admitted *+ referra" form Ph+sician on sta,
Patient discharged to Fami"+ care
A"" nursing entries signed *+ name
and date
-es
Nursing entries sho. .eather
made *+ $rofessiona"/ $ractice/
student nurse or other
-es/ there .as a signature o&er $rinted
name at the end of the charting or
orders.
Patient0s c"othing/ &a"ua*"es and
other $ersona" items .ere
accounted in accordance .ith
$o"ic+
No/ there .ere no documentation and
not re1ected in the chart/ the c"ient0s
&a"ua*"es .ere gi&en or accounted to
signi2cant other as $art of the
institutiona" $o"ic+.
3$eration and other $atient or
fami"+ consent forms com$"eted as
re4uired *+ $o"ic+
'onsent forms are signed *ut not
com$"eted and the $atient0s re"ation to
the nearest 5in is not stated.
%ere there an+ accidents or other
s$ecia" incidents6
No an+ incidents or other acccidents
ha$$en.
7ardex in use6 -es/ 7ardex .as used as $art of the
institutiona" $o"ic+.
8f +es/ 7ardex *ecomes $art of
$ermanent chart6
-es/ 7ardex *ecomes $art of $ermanent
chart.
A nursing care $"an is recorded in
charts
No/ it is not inc"uded in the $atient0s
chart.
Admission entr+ sho.s
assessment of $atients condition9
Ph+sica"
-es/ the entr+ sho.s the condition of the
c"ient/ it .as .ritten in the histor+ of
$resent condition.
:motiona" No/ it is not inc"uded on the charting
.hether the $atient is a.a5e/
res$onsi&e or coherent.
Nursing discharge entr+ sho.s
assessment of $atient0s condition9
Ph+sica"
-es the "ast entr+ of the sta, in the
discharge $"an sho.s that the $atient
.as in fair condition.
:motiona" No/ there is no emotiona" assessment
in the charting of the sta,.
A. Application and Execution of Physicians Orders
Sco
re
Sco
re
Avera
ge
1.!edica" Diagnosis com$"ete (here .ere no !edica"
diagnosis/ and the chart on"+
sho.s the admitting diagnosis
;(herma" Burn) Face and Pa"m<
=. 3rders com$"ete -es the doctors order is
com$"ete it has date and time.
(he route/ dosage and
fre4uenc+ of the medications
are a"so stated.
3.3rders current A"" $h+sicians order .as
.ritten .ith current date and
time. >ita" signs on the
$rogress notes .ere a"so
$resented.
?. 3rders $rom$t"+ executed A"" orders are carried out *+
nurses .ith signature and date.
#o.e&er the timing *et.een the
gi&ing of order and its execution
is not $ro$er"+ o*ser&ed. But
S(A( orders .ere gi&en
immediate"+.
5.:&idenced that nurses
understood cause and e,ect
Nurses .ere a*"e to assess
and document the 2ndings in
the charting) and the+ a"so
inc"uded the actions and
res$onse in their
documentation.
@.:&idence that nurses too5
histor+ into account
#istor+ ta5ing .as done and it
.as re1ected in the chart) *ut it
.as incom$"ete the histor+ of
$resent i""ness is not com$"ete
and some assessment is omit.
TOTAL
PART II.
. O!servation of Sy"pto"s and Reactions
Sco
re
Sco
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Avera
ge
A.Be"ated to course of a*o&e
disease;s< in genera"
Nurses notes re1ected that the+
understand the case of the $atient *ase
on their inter&entions and 5no.ing .hat to
assess and .hat $recautions are to *e
a$$"ied.
C. Be"ated to course of a*o&e
disease;s< in $atient
Nurse0s notes on"+ sho.ed the carried
orders and the inter&ention done to
$atient. !ost of the assessment seen in
the chart .as focusing on the disease
manifestations as o*ser&ed *+ the nurse.
D.Be"ated to com$"ications
due to thera$+
Nurse0s notes do not sho. .arnings on
.hat is ex$ected and not ex$ected side
e,ects of medicine that shou"d *e
o*ser&ed and *e re$orted. 3n"+ the
insertion of 8> 1uids is inc"uded.
10.>ita" Signs Nurse0s notes inc"ude com$"ete &ita" signs
in the 1o. chartE(PB sheet. %ith $u"se
rate/ res$irator+ rate and tem$erature. No.
of urine and *o.e" .as a"so recorded.
11.Patient to his condition (he $h+sica" and $h+sio"ogica" condition of
the $atient .as on"+ gi&en im$ortance in
the charting. (he nurse shou"d inc"ude
emotiona" as$ects of the c"ient and the
fami"+ in the assessment.
1=.Patient to his course of
disease
(he $atients $s+cho"ogica"/ socia" and
s$iritua" as$ect .as ne&er *ecome a focus
and is not gi&en so much attentionE
inter&ention.
TOTAL
#. Supervision of the Patient
Sco
re
Scor
e
Avera
ge
13.:&idence that initia"
nursing diagnosis .as made
(here is no e&idence initia" nursing
diagnosis in the chart. (he 2rst entr+
of the nurse .as the in.ard referra" or
the *ringing of the $atient from :B to
the .ard.
1?.Safet+of the $atient Nurse0s note doesn0t sho. the safet+
$recautions $ro&ided to the c"ient.
!a+*e it .as $art of the hos$ita" $o"ic+
*ut it .asn0t recorded and
em$hasiFed.
15.Securit+ of the $atient Nurses notes on"+ sho.ed e&idenced
that $atient0s securit+ .as secured as
documented) as .e"" as the $atient0s
con2dentia"it+
1@.Ada$tation (he chart do not e&idenced the
$ro&ision of a comforta*"e
en&ironment suita*"e for c"ient0s
reco&er+. Nurse0s note doesn0t sho.
the attem$t to he"$ $atient adGust to
her condition.
1A.'ontinuing assessment of
$atient0s condition and
ca$acit+
(he note sho.s the current status and
situation of $atient) it a"so sho.s the
actions and res$onse of the c"ient on
the di,erent inter&entions.
1C. Nursing $"ans changed in
accordance .ith assessment
(he nurse0s notes is a $ro*"em focused
assessment) the+ focus on the
changes of the $ro*"ems *eing
manifested *+ the c"ient/ the+ a"so
sho.ed modi2cation on the $"an of
care.
1D. 8nteraction .ith fami"+
and .ith others considered
Nurse0s notes do not re&ea" e&idence
of concern for the $eo$"e in contact
.ith the $atient such as in&o"&ing
them in the $"an of care.
TOTAL
$. Supervision of those participating in care %except physician&
Sco
re
Score Avera
ge
=0.'are taught to $atient/
fami"+/ or others/ nursing
$ersonne"
(here .ere no recorded hea"th
teachings done *+ the nurse. (he
nurse doesn0t inc"ude signi2cant
others in the $"an of care.
=1.Ph+sica"/ emotiona"/
menta" ca$acit+ to "earn
considered
(here is no su*Gecti&e data form
the c"ient a*out her a*i"it+ to "earn
and readiness for a *etter hea"th
condition) there is a"so no record
a*out the com$"iance of the
signi2cant others.
==.'ontinuit+ of su$er&ision
to those taught
(he chart doesn0t sho. an+
e&idence that the nurse gi&es
$ro$er hea"th teachings to the
c"ient. (he nurse shou"d $ro&ide
information that .i"" he"$ c"ient for
fast reco&er+.
=3.Su$$ort to those gi&ing
care
(he notes doesn0t re1ect that the
nurse gi&e emotiona" and $h+sica"
he"$ to those .ho accom$an+ and
su$er&ised the c"ient.
TOTAL
E. Reporting and Recording
=?.Facts on .hich further
care de$ended .ere recorded
Sco
re
A"" of the nurse0s notes re1ected
the care rendered *+ the nurse and
the di,erent carried out orders.
(he 5ardex .as a"so $ro$er"+
signed.
Sco
re
Avera
ge
=5.:ssentia" facts re$orted to
$h+sician
(he chart sho.s that there .ere no
essentia" facts re$orted to
$h+sician.
=@.Be$orting of inc"uded
e&a"uation thereof
(here is no e&idence that the nurse
re$orts facts and nursing Gudgment
concerning the $atient0s
conditions. (he+ use the format
FDAB in recording c"ient0s
condition.
=A.Patient or fami"+ a"erted
as to .hat to re$ort to
$h+sician
(he $atients com$"aints .as
e&idence in the chart during
admission/ there .ere histor+ of
$resent condition and $h+sica"
assessment ho.e&er the chief
com$"aint .as not c"ear"+ stated.
=C.Becord $ermitted
continuit+ of intramura" and
extramura" care
HBecei&ed $atient .ith an ongoingI
is a statement of charting sho.ing
there is a continuit+ of care and
a"so the di,erent entr+ of the
nurse e&er+ shift.
TOTAL
'. Application and Execution of nursing procedures and techni(ues
Sco
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Sco
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Avera
ge
=D.Administration andEor
su$er&ision of medications
Some medications .ere not gi&en
and the sign or initia" of the nurse
.as not re1ected in a"" the entr+ in
medication and treatment sheet.
30.Persona" care ;*athing/
ora" h+giene/ s5in nai" care/
sham$oo<
(he charting sho.s that there .ere
a de*ridement done for the care of
the c"ient. 3ther $ersona" care
.ere not documented "i5e *ed
side/ ora" h+giene and *athing.
31.Nutrition;inc"uding s$ecia"
diets<
(he on"+ nursing inter&ention
a*out nutrition is DA( diet ad&ised
during the discharge $"an. 3ther
s$ecia" inter&entions on diet .ere
not inc"uded.
3=.F"uid *a"ance $"us
e"ectro"+tes
8nter&ention re"ated to 1uid $"us
e"ectro"+tes .as the administration
of 8> thera$+ of PNSS 1J at
?0ggtsEmin.
33.:"imination (here is no inta5e and out$ut
monitoring in the chart *ut the
c"ient &oided and defecate .as
inc"uded in the &ita" signs sheet.
3?.Best and S"ee$ (here .ere no s$eci2c inter&ention
that sho.s the nurse concern
a*out rest and s"ee$ of the c"ient.
35.Ph+sica" Acti&it+ 8t is not stated in the chart that the
c"ients acti&it+ .i"" *e changed or
modif+.
Sco
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Sco
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Avera
ge
3@.8rrigations ;inc"uding
enemas<
8rrigations .ere not indicated to
this $atient.
3A.Dressings and *andages (he c"ient has a *urn *ut there
is no entr+ a*out dressings and
*andages a$$"ied to the c"ient.
3C.Forma" exercises $rogram 8t is not a$$"ica*"e since the
c"ients condition does not
re4uire a forma" exercise
$rogram.
3D.Beha*i"itation ;other than
forma" exercise<K
encouragement to.ard
inde$endent "i&ing
(here is no e&idence of
encouragement to.ard
inde$endent "i&ing.
?0.Pre&ention of
com$"ications and infections
(he inter&entions inc"ude
de*ridement and gi&ing of
anti*iotic;cefuroxime< and
ana"gesic ;mefenamic acid<
?1.Becreation/ di&ersion (here .ere no acti&ities stated
to di&ert the attention of the
c"ient/ as .e"" as for recreation.
?=.'"inica"$rocedures-
urina"+sis/BEP
(he c"ient .as su*mitted to
'B'/ Lrina"+sis and Feca"+sis.
Besu"ts .ere a"so attached to
chart.
?3.S$ecia" treatments (here .ere no s$ecia"
treatments or inter&entions
done to the c"ient.
??.Procedures and
techni4ues taught to $atient
Nurse0s note doesn0t sho. an+
hea"th teachings or an+
$rocedures and techni4ues
taught to $atient.
TOTAL
). Pro"otion of physical and e"otional health !y directing and teaching
Sco
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Sco
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Avera
ge
?5.P"ans for medica" emergenc+
e&ident
!edications .ere re&ea"ed on
the treatment sheet and in
the 7ardex/ *ut side e,ects
and ex$ected outcome .ere
not ex$"ained and not
documented.
?@.:motiona" su$$ort to
$atient
(he nurse0s notes do not
sho. as re&ea" that the nurse
encourage $atient or e&en
the fami"+ to &er*a"iFe
concern regarding the
$resent hea"th condition.
?A.:motiona" su$$ort to
fami"+
(he chart did not re&ea" an+
emotiona" su$$ort to an+
signi2cant other.
?C.
?D.
50.Action ta5en in regard to
needs identi2ed
'harting re&ea"s that the
inter&entions rendered .as in
res$onse and .ith regards to
the needs of the c"ient. (he
care .as connected to the
$ro*"em.
TOTAL
O*ERALL TOTAL
PART III+ A,$IT RES,LTS
Patient __
Num*er of records re&ie.ed9
3&era"" e&a"uation *+ num*er of cases
:xce""ent Mood 8ncom$"ete Poor Lnsafe
'unctions Excellent )ood Inco"ple
te
Poor ,nsafe Total
A. A$$"ication and :xecution of Ph+sician0s
3rders
B. 3*ser&ation of S+m$toms and Beactions
'. Su$er&ision of the Patient
D. Su$er&ision of those $artici$ating in care
:. Be$orting and Becording
F. A$$"ication and :xecution of nursing
$rocedures and techni4ues
M. Promotion of $h+sica" and emotiona"
hea"th *+ direction and teaching
(ota"
PART III+ A,$IT RES,LTS
Patient __
Num*er of records re&ie.ed9
3&era"" e&a"uation *+ num*er of cases
:xce""ent Mood 8ncom$"ete Poor Lnsafe
'unctions Excellent )ood Inco"ple
te
Poor ,nsafe Total
A. A$$"ication and :xecution of Ph+sician0s
3rders
B. 3*ser&ation of S+m$toms and Beactions
'. Su$er&ision of the Patient
D. Su$er&ision of those $artici$ating in care
:. Be$orting and Becording
F. A$$"ication and :xecution of nursing
$rocedures and techni4ues
M. Promotion of $h+sica" and emotiona"
hea"th *+ direction and teaching
(ota"