You are on page 1of 23

I.

HOSPITAL AUDIT Patient A Patient B Patient B Male 58 year old August 10, 2011 August 15, 2011 Saint Louis University Hospital of the Sacred Heart Second floor Medical ward Private room Perforated Peptic Ulcer Disease; Hypertension; Coronary Artery Disease; Bronchial Asthma partly controlled, not in exacerbation Dr. Arellano Family care Yes

Name of patient: Gender Age Date admitted Discharged date Name of institution

Patient A FEMALE 62 years old August 23, 2011 August 28, 2011 Saint Louis University-Hospital of the Sacred Heart Second Medical Ward Acute Gastroenterititis, Moderate Volume Depletion, Coronary Artery Disease, Antero Lateral Wall Ischemia, Tachycardia, Premature Atrial Contraction, Premature Ventricular Contraction, and Hyponatremia Physician on Staff Family Care Yes

Floor Medical supervision Complete Diagnoses

Admitted by referral from Patient discharged to All nursing entries signed by name and dated

Nursing entries show whether made professional, practical, student nurse, or other

by

Yes

Yes

Patients clothing, valuables, and other personal items were accounted for in accordance with policy Operation and other patient or family consent forms completed as required by policy Were there incidents? Kardex in use? If yes, kardex becomes part of permanent chart? A nursing care plan is recorded in charts Admission entry shows assessment of patients condition: Physical Emotional Nursing discharge entry shows assessment of patients condition: any accidents or other special

Yes

Yes

Yes

Yes

No

No

Yes No No Yes

Yes No Yes Yes

No

Yes

Yes Physical Emotional No

Yes

No

II.

NURSING AUDIT Function Score Patient A Justification Scor e Patient B Justification Averag e

I.

APPLICATION AND EXECUTION OF PHYSICIAN S ORDER diagnosis 7/7 YES The diagnosis is clear enough to permit intelligent execution of the nursing functions. The patients final diagnoses were: Acute Gastroenterititis, Moderate Volume Depletion, Coronary Artery Disease, Antero Lateral Wall Ischemia, Tachycardia, Premature Atrial Contraction, Premature Ventricular Contraction, and Hyponatremia. The different diagnoses conform in terminology with that of the international classification of diseases published by the U.S. Department of Health, Education and Welfare. That i s why we scored it as 7. YES The orders were complete since it is clear, explicit and conclusive in regard to patient as well as to the diagnosis and other clinical data.

1. Medical complete

2. Orders complete

7/7

Orders for medications included dosage, frequency, and route of administration. Though some medication orders the physician did not specify the route of administration (e.g. Paractamol 500mg i tab PRN for fever) since it is clear from the nature of medications. Other therapeutic management were clearly specified. Orders were also written with time and date. 3. Orders current 7/7 YES Date and time the order were given present and updated on a 24 hour basis according to assessments and evaluation done by health care professionals. UNCERTAIN It is uncertain since some orders were carried out without indicating time. Orders should be carried out within 15-30 minutes depending on its type. The chart should show reasonable and appropriate timing between the giving of the order and compliance with it.

4. Orders executed

promptly 3/7

5. Evidence that nurse 0/7 understood cause and effect 6. Evidence that nurse 7/7 took health history into account TOTAL II. 31

NO

YES

Interpretation: Good

Interpretation:

OBSERVATION OF SYMPTOMS AND REACTIONS YES 7/7 A score of 7 was given because it was noted that majority of the nurses progress notes were completely and directly related to the patients situation and needs. All of them demonstrated patientcentred care, taking in consideration the patients present condition and patients complaints that gave them the clinical base in planning for their nursing care plan and rendering immediate nursing interventions. YES A score of 7 was given because it was noted that majority of the nurses progress notes were completely and directly related to the patients situation and needs. All of them demonstrated patientcentred care, taking in consideration the patients present condition and patients complaints that gave them the clinical base in planning for their nursing care plan and rendering immediate nursing interventions. Initial assessment revealed 1. RUQ direct tenderness 2. (+) murphys sign 3. Guarding and grimacing noted 4. moans at times

7. Related to course of 7/7 above disease in general

5.Irritable 6. with intermittent diaphoresis noted All these findings were documented by the staff nurse and student nurse. These findings are in accordance with descriptions provided in textbooks regarding the disease process.

8. Related to course of 7/7 above diseases in patient

YES The chart shows that the nurse understood the disease in general as evidenced by documentation of appropriate signs and symptoms related to the general disease, and relevant interventions were done addressing the problem.

YES During the patients confinement, and after his surgical intervention which is Emergency Exploratory Laparotomy and Cholecystectomy. It was observed to the patient that after his operation, he was able to tolerate the operation without any complications, with an aldrete score of 7/10, and still recovering from the anaesthesia. During the last few days of hospitalization, he was observed to have intact and dry dressing over the surgical wound, no presence of infection, ambulatory, able to perform ADL with minimal assistance, still rated pain as 5/10, with pale palpebral conjunctiva as indicated in the

progress notes. Other than these, there were no other documented observations and cues about the patients individual response to his condition as brought about by external factors. 9. Related complication therapy to 3/7 to UNCERTAIN Complications of therapies were not documented and it is uncertain whether there really was. UNCERTAIN A score of 3 out of 7 was given because of the documented observations and cues shown by the patient. As seen at the progress notes, interventions done were included, Advice to take prescribed drugs regularly, Adviced to increase protein rich food for wound healing and reinforced deep breathing exercise. There were no noted documents regarding the complications the patient may observed, anticipate or watch out for about his condition and the side effects of the medications given to him. UNCERTAIN Regular monitoring of vital signs at the TPR sheet and flow sheet was presented though, however the noted vital signs at the progress notes do not coincide with the recorded values that shows a

due

10. Vital signs

7/7

YES There is a section in the chart wherein vital signs were plotted in order to clearly see the patterns and trends in the vital signs.

significant discrepancies between the time, date and the shift it was taken. In the over all, some of the criteria were described in the chart but some do not. 11. Patient to his condition 3/7 UNCERTAIN In this category, attention should be given to the patient in which case, a careful consideration of behaviours should be done reflective of the attitude of the patient this includes use of direct, indirect , and reflective questions to the patient aimed at eliciting attitudinal response as well as observation of nonverbal behaviour. The chart only shows the nonverbal behaviour of the patient (e.g. irritable at times, loss of appetite noted) but there was no evidence that showed that the nurse did not include the assessment of the attitude nor did they address the behaviour shown. UNCERTAIN There were some evidences but not enough to conclude that they have given attention to the demonstrable were some YES It was observed and evidently shown at the progress notes that the patients attitude toward his condition was given attention and importance. As evidenced by the patients verbatimMedyomasakitnalangyun gsugatko., Etomedyo okay naman, katataposlangngoperasyonkokaha pon.This proves that student nurse and staff nurse carefully considered the patients behaviour, attitude and responses that reflect his present condition.

12. Patient to his course of 2/7 disease

UNCERTAIN There were no seen documentations of any observation and assessment demonstrating the patients

evidences but not enough to conclude that they have given attention to the demonstrable degree of the patients understanding and acceptance toward her specific disease.

acceptance, understanding, and concerns regarding his condition and disease. It was not presented and not accommodated in the daily monitoring, observation, and rendering care to the patient. Lack of information was observed, though some were presented in the chartings. Interpretation:

TOTAL III.

Interpretation:

SUPERVISION OF THE PATIENT YES 4/4 In the nurses notes, the patient presented with loose bowel movement and loss of appetite, the nurses identified problem was risk for deficient fluid volume. This shows that a nursing problem was determined as a basis for formulating a nursing care plan. It is obvious that initial nursing diagnosis was done. Yes The chart shows a nursing diagnosis as soon as the patient was admitted in the ER, where the first contact between the patient and the nurse, student nurse happened: Acute pain was identified as the initial diagnosis and was addressed properly. According to Phaneuf, a nursing diagnosis should be made as soon as possible after the first nursing contact with the patient to give a yes judgment. Yes At least half of the progress notes

13. Evidence that initial 4/4 nursing diagnosis was made

14. Safety of patient

4/4

YES 4/4 There is recorded evidence that precautions were made to prevent

injury. Safety of the patient ensured through the assessment of the muscle strength, assistance in ADLs, promotion of rest, stayed at bedside and others.

made addressed the safety of the patient, most especially after the operation. Some of which were: Raised side rails and staying with the patient. These interventions could have decreased anxiety and fear, prevented physical injury and increased self- confidence and trust and rapport between nurse and patient. However, there were no recorded data supporting such results. Uncertain Some of the nursing interventions documented were addressed for the maintenance of the patients therapeutic environment such as: Providing a quiet environment. However, there was no evidence of interventions geared towards support of patients productive interpersonal relationship. Yes Attempts were made to help patient to adjust to the course of his illness like teaching the patient how to do DBE when patient was in pain as the result of the operation; teaching how to splint the wound when coughing.

15. Security of patient

4/4

YES The chart showed evidence of work that helps in maintaining a therapeutic environment through attention to the physical setting where interactions occur.

16. Adaptation

UNCERTAIN There were recorded attempts to help the patient adjust to his condition, which was reflected from the nurses observations, which also addressed the anxiety of the patient. But there were no written record as to whether there is attempt to help the patient

4/4

accept therapeutic goals, develop confidence in the care in accordance with her capacities which is why this subsection was scored 3. 17. Continuing 1/4 assessment of patient condition and capacity UNCERTAIN 4/4 The chart reflects specific assessments to support the problem but it seems that the content of nurses notes in every shift contains the same thing, the same assessment for the same problem another thing is that when a new nursing diagnosis was identified, the succeeding ones does not evaluate whether the problem has already been resolved. But it attained a score of 3 because there are some evidences that reflect evaluation of the current status of the patient. UNCERTAIN 4/4 The nurses notes reflects that nursing diagnoses were identified depending on the current presenting signs and symptoms of the patient but most of the notes have the same interventions despite the change or resolution of Yes Nursing diagnoses made in relation to the patients condition were mostly acute pain, impaired skin integrity. These diagnoses reflect ongoing evaluation of the patients current status and situation. There were evidences of improvement according to the documented objective and subjective data, exemplified by the patients verbalization okay naman na ako, di na gaanong masyado masakit.

18. Nursing plan changed accordance assessment

are in with

Yes Nurses and student nurses alike are required to render a patient centered care, which was evident by the SOAP Charting made by the student nurses. The nursing care plans focused on the daily condition of the patient.

the first few identified problems. 19. Interaction with family 0/4 and others are considered NO 0/4 The chart does not reflect observations regarding patients interactions with family, physician and significant others. No Basing from the SOAP charts documented, there were no evidence of interactions or encouragement of significant others to support the patients needs. Interventions were only centered to the patient, including the teachings that need also to be taught to the other person involved in the patients care. Interpretation:

TOTAL IV.

Interpretation:

SUPERVISION OF THOSE PARTICIPATING IN CARE UNCERTAIN 2/5 The chart shows some health education addressing the patients condition but not to the other member of the medical team involved with the patients care. NO 0/5 There is no written record that shows that physical, emotional and mental capacities were taken into consideration, which is why this subcomponent is scored 0. Uncertain There were a lot of documented teachings to the patient; however evidence of evaluations done to check if these teachings were followed were not indicated. No Nurses and student nurses alike need to assess the patients ability to learn, including the patients educational, emotional and behavioural status before

20. Care taught to patient, 2/5 family or others, nursing personnel

21. Physical, emotional, 0/5 mental capacity to learn are considered

Because there should be initial and continuing assessments of the need for and appropriateness of that which is to be taught.

conducting any health teachings to ensure that topics being taught are grasped by the patient. However, there were no data presented that these are being assessed before teaching interventions were conducted. No This subcomponent, in order to be met must have evidence that the teachings were effective as evidenced by the patients manifestations of the desired behaviour. Nevertheless, there were no data that such as these are manifested.

22. Continuity of 0/5 supervision to those taught

NO 0/5 There has been no follow-up regarding the teachings that has been done. According to explanation of audit schedule components, teaching has not occurred until it is reflected in the behaviour of the learners which was not reflected in the chart, hence follow-up of what has been taught was not evident. NO Here, the continuing ability and taught, with accordance which was chart. 0/5 emphasis is on assessment of the readiness of those appropriate action in with the assessment not reflected in the

23. Support of those giving 0/5 care

No There were no data regarding the support of care. The chartings did not reflect the emotional status of the patients significant other.

V.

REPORTING AND RECORDING

24. Facts on which further 4/4 care depended were recorded

YES 4/4 There were evidence information on the clients reactions and symptoms, evidence of the execution of the clients physician orders.

Yes Evidence by the physician and nurses being able to provide management in the clinical area through the countersigned doctors order and nurses documented the patient care rendered. Yes The chart showed that nurses were able to refer facts to the physician either through writing and verbally. Yes There is evidence that, in reporting facts, nursing judgment concerning their significance or possible importance is included.

25. Essential facts 4/4 reported to physician

YES 4/4 There was evidence that the nurse referred reports with regards to patients health and development. Unusual signs and symptoms were reported as well YES 4/4 There was evidence that the judgments of nurses were also considered in performing procedures to the client.

26. Reporting of facts 4/4 included evaluation

27. Patient or family 4/4 alerted as to what to report to physician

YES 4/4 There was evidence indicated to report any unusual signs and symptoms by the patient to the physician.

Yes Almost all of the nursing care plans had interventions that alert the patient as to what to report to the physician like: Instructed patient to report any discomfort. Yes

28. Record

permitted 4/4

YES

4/4

continuity of intramural and extramural care

The chart showed continued nursing plans of care and responsibility for direct reporting to the physician. Information was placed on the chart so as to have continuity of care.

It has been shown in the chart the sequence of care from physician to nurse and student nurse and to other professionals and medical personnel as evidenced by the nurses carrying out the doctors order and the presence of the laboratory results accomplished by the laboratory department ordered by the physician.

VI.

APPLICATION AND EXECUTION OF NURSING PROCEDURES AND TECHNIQUES and/or 0.5/2 of UNCERTAIN For every medication, there are anticipated therapeutic effects and possible untoward side effects, including reactions. In the chart, nurses who handled the patient was able to administer medications on the right time, dose and condition (PRN) but unable to document if health teaching regarding the medications are not indicated.

29. Administration supervision medications

30. Personal care 0/2 (bathing, oral hygiene, skin nail care, shampoo)

NO The chart did not indicate attention to personal care whether the care activities are performed by the patient, a family member, or another person since it is none of

this were documented in the chart.

31. Nutrition (including 2/2 special diets)

YES There is evidence of attention to adequate nutrition as appropriate to the patients condition, course, and stage of growth and development. There are no special diet indicated for the patient

32. Fluid balance electrolytes

and 2/2

YES The chart reflects consideration of possible disturbances in body fluid and electrolyte balance, as indicated by the patients age, condition (with episodes of LBM), and course of illness. There is evidence of attention to the fluid and electrolyte balance of the patient specially that the patient has episodes of LBM. Necessary assessment, interventions and health teachings were documented in the chart. YES Evidence of bowel function is considered, and appropriate actions is also taken and well documented. Elimination, including the characteristics of stool, its amount is documented. Urination

33. Elimination

2/2

frequency and amount has also given attention and documented. 34. Rest and sleep 2/2 YES According to the chart, the patients patterns of rest and sleep are taken into account in planning his regimen and supervising his care. Interventions in facilitating adequate rest and sleep are always given attention. Health teaching regarding the importance of rest and sleep is also done and documented. YES The chart was able to show the activity which the patient engages and the activity which is clinically permissible. The charts were able to show the patients usual activity, mobility, ability to do ADLs and restrictions due to a specific condition. Aside from proper assessment, there are also evidence that health care givers were able to facilitate usual healthy activities through assistance and health teachings. DOES NOT APPLY There is no need for irrigation of wound, canals and cavities in the case of the patient.

35. Physical activity

2/2

36. Irrigation(including enemas)

2/2

37. Dressings bandages

and 2/2

DOES NOT APPLY There are no dressings and bandages applied to the patient during the hospitalization YES The chart shows evidence that the treatment plan carried out as ordered by the physician. Physicians orders were routinely carried out and supportive encouragements and assistance were also given to the patient as documented. YES The chart shows evidence of assistance, health teaching and encouragement towards independent living activities of daily living. Activities of daily living require motivation and participation in decision making which leads to the activities as well as to the ability to perform them. Assessment of the performance were done and evaluation was reflected by the next nurse on duty. The encouragements documented may reflect the knowledge and understanding of this. YES

38. Formal program

exercise 2/2

39. Rehabilitation(other than formal exercise)

2/2

40. Prevention

of 2/2

complications infections

and

Evidence of work toward early detection of risk problems was present and well documented. Consideration of complication that might reasonably be expected were and prevented through ongoing nursing care 0/2 NO No recreation and diversion activities assessment and interventions were documented in the chart YES The chart shows results of urinalysis and other examinations done by the nurses. The chart also shows the result of these examinations DOES NOT APPLY The patient has no special treatments . indicated

41. Recreation, diversion

42. Clinical procedure urinalysis, B/P

2/2

43. Special treatments 2/2 (e.g., care of tracheotomy, use of oxygen, colostomy or catheter care, etc.) 44. Procedures and 2/2 techniques taught to patient

YES There were evidence that techniques that the patient can learn to carry out to his own advantage especially those that are related to her condition were taught. Necessary techniques

were taught to the patient, included to these were techniques to prevent complications such as dehydration.

VII.

PROMOTION OF PHYSICAL AND EMOTIONAL HEALTH BY DIRECTION AND TEACHING UNCERTAIN 0/3 The hospital may have specific policies for the management of major emergency situations but it is not clearly stated or placed in the patients chart. The patient together with her family may not know precisely what facility to use in an emergency, and how to use it UNCERTAIN There was 1/3 evidence that a nurse addressed the emotional aspect of the patient but it was not consistent with the other nurses. No There were no noted plans for medical emergency in the chart of the patient. It is not indicated and included in the nurses progress notes about special precautions and specific teachings and guidelines taught to the patient and significant others during an emergency situation. Uncertain A score of 1 out of 3 was given because some of the observations documented about the patients feelings and concerns are just about the patients feelings towards pain. Some emotional supports was shown and written at the nurses progress notes though assessment about the characteristics of the behaviours, psychosocial, and cultural matrix, which would help them provide

45. Plans for medical 1/3 emergency evident

46. Emotional support to 1/3 patient

emotional support needed by the patient was not addressed. And most of the interventions were addressed only to the needs and of medical care. 47. Emotional support to 0/3 family NO 0/3 The nurse did not reflect impressions and facts about family reactions toward the patient and her condition. This supposedly can help the family accept the patients condition and feelings.0 No Emotional support to the family was not presented on the nurses progress notes. It was not shown that they had addressed also the emotional needs by the patients family and only focuses on the patient itself alone. Yes It is noted in the chart that nurses progress notes included the teachings about the patients prevention of acquiring infection, on avoiding lifting heavy objects, on performing DBE, and detection for signs and symptoms of infection. They also include in emphasizing the importance of proper hand washing and proper hygiene. Uncertain A score of 1 out of 3 was given because discharged plan is found

48. Teaching promotion 3/3 and maintenance of health

YES 3/3 There was an evidence that the nurse address preventive and promotion measures in order to avoid some diseases and to improve ones health.

49. Evaluation of need for 0/3 additional resources (e.g., spiritual, social service, homemaker

NO 1/3 The evaluation of the need for additional resources did not occur periodically throughout the time

service, physical or occupational therapy)

the patient is under care.

in the patients chart for continuation of care though evaluation for additional need for resources was not noted. This alone is not sufficient data and information to prove that was evaluation of the need for additional resources. It was noted in the discharge plan that home medications and follow up check up was only included but no further information was given. Yes Nursing interventions rendered and given to the patient were appropriate to the current and present needs identified by the patient. Actions to solve and alleviate the patients problem was emphasized and observed at the progress notes. Pain and skin integrity nursing diagnosis presented the following interventions: 1. Maintained aseptic technique in cleaning the patients wound 2. Provided safety by positioning patient away from the edge of the bed 3. Encouraged deep breathing exercise

50. Action taken in regard 3/3 to need identified

YES 3/3 Nursing actions were taken with the knowledge of the patients physician.

4. Instructed to do splinting when coughing 5. Guided and educated patient on proper hand washing before and after cleaning his wound

You might also like