Tracer Pain and Staff Member Essay

Tracer Pain and Staff Member Essay Tracer: Pain and Staff Member Essay Surgical Patient Surgical Patient Tracer Worksheet Nightingale Community Hospital – in Year 2 of Audit Cycle MR#__453355______________________ Admission/Service Start Date:___________ Language/Culture:_English_____________ Tracer Surveyor(s): Sequence of Care/Services 1._Surgical Date Admitting/Presenting Dx/Condition: Nursing Unit__________ 2. _Radiology_______________________ 3. _OR_____________________________ 4. _PACU__________________________ Admitted with post-op wound infection Went to surgery for drainage Long term antibiotics Supportive spouse Plan home health at discharge Current Location _Surgical Nsg Unit ___ Questions / Actions Ask the staff member to give you a report on the patient like he/she may give to an oncoming shift. Notes/Deficiencies Identified Tracer Tips Does the staff member know the course of care? Show me the patient’s admission assessment (or initial nursing assessment). When is the assessment done? By whom? Can an LPN do an admission assessment? History and physical not done within 24 hours of admission ( 72 hours) Review admission history Ask nurse about any gaps or blank areas Should be completed by end of shift when pt admitted Ask about med reconciliation process How is care plan generated? Describe the medication reconciliation process. Primary nurse able to verbalize med reconciliation process. Review of chart had evidence of med reconciliation on admission and after surgery Where is your functional assessment? OR What precipitates PT, OT, or SLP referral? Function assessment triggered based on admission assessment but no documentation found Nutritional assessment documented Home med list is obtained and verified at time of admission Med recon done when patient transfers location (OR to floor, floor to floor, ICU to floor, etc) Med Recon is done at discharge- any discrepancies and nurse can hold up discharge Have staff show f/u if a referral was triggered. Where is your nutritional assessment? Have staff show dietitian’s f/u if a referral was triggered. What would precipitate a social work referral? Nurse verbalized indications for social work referral Have staff show social worker’s f/u if a referral was triggered Does this patient have advance directives? Where is it documented? Is a copy of the document in the medical record? Nurse said patient has an advance directive but did not bring it with her. Family was reminded a copy was needed but failed to bring in. If patient does not have Advance Directive, was information provided? What are the patient’s allergies? No allergies Note allergies on all documents where they are documented (ie, H&P, ED, MAR) and whether all sources agree. Does this patient have any cultural/ spiritual needs? Priority Focus Areas (PFA) Addressed: ïÆ' ¾ Assessment & Care/Services ïÆ' ¾Communication Credentialed/Privileged Practitioners Equipment Use ïÆ' ¾ Infection Control Information Mgmt ïÆ' ¾ Medication Mgmt Organization Structure Orientation & Training ïÆ' ¾ Rights & Ethics Physical Environment ïÆ' ¾ Quality Improvement ïÆ' ¾ Patient Safety Staffing Coach staff to avoid responses with â€Å"usually†, â€Å"sometimes,† and other descriptions that could indicate that the practice is not consistent. Questions / Actions Is this patient at risk for skin breakdown problems? Where is it documented? What breakdown prevention measures are taken? Notes/Deficiencies Identified Is this patient at risk for falls? Where is it documented? How is the risk for falls communicated shift to shift? Dept to dept? What precautions have been implemented for this patient? Yes. Documented in the nursing admission assessment. Fall risk is included in handoff form. Precautions: slip proof socks, night light Does this patient have a plan of care? How are care plans updated or changed? How do all disciplines come together for a plan of care? Initial nursing plan of care documented but not updated since surgery. Interdisciplinary Rounds (IDR) or Caring Rounds Are IDR documented? Are