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 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 5 If functional screen positive, plans for follow-up documented. PC.01.02.01, EP 4 6 Nutritional screen complete. PC.01.02.01, EP 4; PC.01.02.03, EP 7 7 (Outpatient Only) If nutritional screen positive, plans for follow-up documented. PC.01.02.01 EP 4; PC.01.02.03 EP 7 8 Pain screen complete. PC.01.02.07, EP 1 & 2 VMG Clinic Intake Form and or CIA or POC in hard chart VMG Clinic Intake Form and or CIA or POC in hard chart VMG Clinic Intake Form and or CIA or POC in hard chart Nutritional screen completed. Positive screen follow up documented on form ; or negative screen = NA Pain screen completed
9 If pain screen positive, plans for follow-up documented. PC.01.02.01, EP 23; PC.01.02.07, EP 3 10 Abuse screen complete. PC.01.02.09, EP 4 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 14 15 Learning needs/education screen complete. 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 documented. PC.02.03.01 EP 10, EP 25 Preferred language for discussing health care documented. 16 PC.02.01.21, EP 1 PC.02.01.21, EP 1 TRACERS - OPERATIVE & OTHER PROCEDURES VMG Clinic Intake Form and or CIA or POC in hard chart VMG Clinic Intake Form and or CIA or POC in hard chart VMG Assesssment & Follow-up for Postive Intake Screen. Positive screen (option C and >3) follow up documented on form; or negative screen = NA Social Environment screen completed. Positive screen follow up documented on form; or negative screen = NA VMG Assessment & Falls screen completed for pts Follow-up. >/= 65 yrs. VMG Assessment & Positive screen follow-up Follow-up. documented on form. VMG Clinic Intake Educational screen Form and or completed. CIA/POC VMG Assessment Positive screen follow-up & Follow-up and or documented on form or CIA/POC negative screen = NA VMG Clinic Intake Form and the Starpanel outpatient white board. CIA/POC 17 Consent form present and signed, dated and timed. RI.01.03.01 EP 13 Consent Form Provider history and physical (H&P) completed and documented H& P form prior to procedure. 18 (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 condition.) PC.01.02.03 EP 5 Documented 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. IM.02.02.01, EP 3 20 Supporting documentation (diagnosis, condition, or indication for use) exists for every order for "current" medications. MM.04.01.01 EP 9 21 Order present for each medication administered. RC.02.01.01, EP 2 Are orders for PRN medications specific such that there is no 22 therapeutic duplication (multiple options for a specific indication) TRACERS - PATIENT EDUCATION 23 All "teaching/education" fields complete, as appropriate (excluding pain management). PC.02.03.01, EP 10, EP 25 Documentation by all disciplines involved in the patient's care, 24 treatment, or services. PC.02.03.01, EP 5 TRACERS - PROBLEM LIST (OP ONLY) 25 Complete (diagnoses, procedures, allergies, meds)? RC.02.01.07 EP 2 All entries in the medical record on date of review including medication orders, problem list, flowsheets, progress notes,etc. Physician orders, H&P, progress notes Physician orders in E Cube Medications list VMG Assesssment & Follow-up for Positive Intake Screen and or patient education form in hard chart Same as above. Paper and individual discipline notes StarPanel - click on Problem list. No " Do Not Use" abbreviations are found in the medical record on the date of review. Diagnosis, condition or indications for use are documented. Order present. 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). All teaching fields are completed as appropriate. Signature(s) & initials are present for appropriate disciplines. All component fields are completed in StarPanel.
26 Updated at every physician visit? RC.02.01.07 EP 3 StarPanel - click on Problem list.and or in Ecube Date of problem list matches most current physician visit.
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? 30 Was hand hygiene performed before putting on gloves? 31 Were clean gloves put on before removing the old CVC dressing? 32 Were gown, protective eyewear and mask or faceshield worn during CVC exit site care? 33 Was a mask placed on the patient covering the nose and mouth? 34 Was the old CVC dressing removed and properly discarded? 35 Was the CVC exit site examined for signs of infection? 36 37 If there was evidence of CVC exit site infection, was the team leader notified? Were gloves removed and hand hygiene performed after the CVC exit site was examined for infection? A new tray/cart was used before putting on gloves 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 Gloves were removed and hand hygiene performed after the CVC exit site was examined for infection
38 Were clean gloves put on before cleaning the CVC exit site? 39 40 41 Was the area around the CVC exit site cleaned with Chlorhexadine or antiseptic using a back and forth motion and beginning at the exit site and working outward toward the periphery? Was the Chlorhexadine or antiseptic allowed to dry before applying the clean dressing? Was hand hygiene performed after CVC exit site care was complete? 42 Was a new sterile dressing applied to the CVC exit site? 43 Were gloves removed following completion of the CVC exit site care? 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 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? 47 Was hand hygiene performed before putting on gloves? 48 Were clean gloves put on before beginning the CVC initiation procedure? 49 Was a mask placed on the patient covering the nose and mouth? 50 Were gown, protective eyewear and mask, or faceshield worn during the CVC initiation procedure? 51 Was a clean field placed under the CVC ports? 52 Were the catheter clamps closed? 53 54 Were the CVC connections disinfected by scrubbing the hub thread for 15 seconds with an alcohol pad and allowed to dry? Were sterile syringes connected to each port with aseptic technique? 55 Was each port aspirated and/or flushed with sterile saline? A new tray/cart was used before putting on gloves 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? 58 Was hand hygiene performed after the CVC initiation procedure was complete? Treatment was initiated successfully Gloves were removed following initiation 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? 62 Was hand hygiene performed before putting on gloves? 63 Were clean gloves put on before beginning the CVC dialysis discontinuation procedure? 64 Was a mask placed on the patient covering the nose and mouth? A new tray/cart was used before putting on gloves before beginning the CVC dialysis discontinuation procedure A mask was placed on the patient covering the nose and mouth 65 Were gown, protective eyewear and mask or faceshield worn during the CVC discontinuation procedure? 66 Was a clean field placed under the CVC ports? 67 Was the extracorporeal circuit reinfused? 68 Were gloves removed following dialysis discontinuation? 69 Was hand hygiene performed before putting on new gloves? 70 Were clean gloves put on before disinfecting CVC connections? 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 before putting on new gloves before disinfecting CVC connections
71 Were the catheter clamps closed? 72 73 Were the CVC connections 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 disconnecting blood lines? 74 Were the blood lines disconnected using aseptic technique? 75 Were sterile port caps applied post treatment using aseptic technique? 76 Were unused supplies discarded? The catheter clamps were closed The CVC connections were disinfected by scrubbing before removing AND by scrubbing the hub thread for 15 seconds with an alcohol pad 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 77 Were gloves removed immediately after completing discontinuation procedure? 78 Was hand hygiene performed immediately after removing gloves? Gloves were removed immediately after completing discontinuation procedure immediately after removing gloves
DIALYSIS - INITIATION OF DIALYSIS WITH AN AVF OR AVG 79 Date of Observation 80 Staff Observed 81 Was a new tray/cart used? 82 Was the tape prepared in the clean area? 83 Was the skin over the access washed with soap and water OR antibacterial scrub? 84 Was the access examined and evaluated prior to cannulation? 85 Was hand hygiene performed before putting on gloves? 86 Were clean gloves put on before cannulation? 87 88 89 Were gown, protective eyewear and mask or faceshield worn during cannulation? Was antiseptic applied to skin over cannulation sites and allowed to dry? Was skin NOT TOUCHED between antiseptic application and cannulation? 90 Was antiseptic applied in a circular motion from inner to outer? A new tray/cart was used The tape was prepared in the clean area The skin over the access was washed with soap and water OR antibacterial scrub The access was examined and evaluated prior to cannulation before putting on gloves before cannulation 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? 93 Was treatment initiated with aseptic connection to blood lines? 94 Were gloves removed following initiation? 95 Was hand hygiene performed after initiation of dialysis with AVF or AVG was complete? 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 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? 100 Was hand hygiene performed before putting on gloves? 101 102 Were clean gloves put on before starting the dialysis discontinuation? Were gown, protective eyewear and mask or faceshield worn during discontinuation? 103 Was the extracorporeal circuit reinfused? 104 Were the bloodlines properly disconnected? 105 Were gloves removed following dialysis discontinuation? 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? A new tray/cart was used The tape was prepared in the clean area before putting on gloves before starting the dialysis discontinuation 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 before putting on new gloves before removing needles Needles were removed with aseptic technique Needles were discarded in the sharps container
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? 115 Were needle sites covered with a clean, dry bandage? 116 Were unused supplies discarded? Needle sites were held with clean gauze using clean gloved hands Needle sites were covered with a clean, dry bandage Unused supplies were discarded 117 Were gloves removed immediately after completing discontinuation procedure? 118 Was hand hygiene performed immediately after removing gloves? DIALYSIS - PATIENT TREATMENT AUDIT 119 Date of Observation 120 Staff Observed 121 122 Does the machine prescribed treatment match the treatment order: Dialyzer matches? Does the machine prescribed treatment match the treatment order: BFR matches? The gloves were removed immediately after completing discontinuation procedure immediately after removing gloves The machine prescribed treatment match the treatment order: Dialyzer matches The machine prescribed treatment match the treatment order: BFR matches
Does the machine prescribed treatment match the treatment 123 order: DFR matches? 124 Does the machine prescribed treatment match the treatment order: Dialysate matches? The machine prescribed treatment match the treatment order: DFR matches The machine prescribed treatment match the treatment order: Dialysate matches 125 Are Vital Signs and safety checks being performed AT LEAST every 30 minutes? 126 Was a patient evaluation performed pre-treatment? 127 If the patient has a catheter, was the Hemosafe Connector applied correctly? documented on flowsheet documented on flowsheet Vital Signs and safety checks are being performed AT LEAST every 30 minutes Patient evaluation was performed pre treatment The Hemosafe connector was applied correctly to a patients catheter 128 Patient has bloodlines, access, and face uncovered during the treatment? 129 Machine alarms are answered and resolved immediately? 130 The wet machine transducer was changed immediately? 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 The patient has bloodlines, access, and face uncovered during the treatment The machinge alarms are answered and resolved immediately The wet machine transducer was changed immediately There is visible evidence of dry or wet blood on the equipment or surfaces
133 Staff Observed 134 Was a patient evaluation performed post-treatment? 135 136 If the patient did NOT achieve prescribed treatment parameters was the RN notified? If the patient had a change in condition during the treatment was the RN notified? 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 documented on flowsheet documented on flowsheet documented on flowsheet documented on flowsheet documented on flowsheet Patient evaluation was performed post treatment RN was notified if the patient did NOT achieve prescribed treatment parameters Nurse notified of a change in condition during the treatment Patient change in condition during the treatment was documented Post dialysis standing BP documented on patient that can stand