CONCURRENT NURSING AUDIT:Patients Chart (Venzon & Nagtalon, 2006) UNIT: Surgery Ward Benguet General Hospital TIME:

9:00 AM Patients Name: CALIS, Jeralyn Diagnosis: Acute Appendicitis, Urinary Tract Infection Directions: Check observations in appropriate column and make necessary justifications: Comments Ye N N Justification Implications s o A FORMAT 1. Nursing history is complete In the History of present illness According to the national core within 24 hours the name, drug, dose and time competencies for Filipino nurses, it is a of administration of the drug must that relevant and comprehensive that the client took were not information to the case must be taken documented. And also the and well documented as according to progression and characteristics the ADPIE process. of pain and other present What can be taken into consideration symptoms were not noted. are the present idiosyncrasies that the patient has with drugs and also renal and hepatic concerns. Also a comprehensive assessment would reveal what could be the presenting problem of the patient rather than just waiting for the physician to identify the problem. 2. Attending Physicians name is The only present is the signature In legal consideration especially in DATE: September 9, 2011

recorded

of the physician.

documentations it is necessary to place the name of the person that would be having an entry to a legal document especially to those information that directly concerns the patient. This also presents the practice of accountability of a person since the physician is one of the members of the health team who has a direct discretion to the case of the patient. What can be a presenting problem in this situation is that what if the patient taken into the institution is not the patient at all. Especially in legal matters, it cannot be argued that the patient is admitted in the hospital since her name is not placed on the consent and/or admission is not approved by the family and/or the patient. Since the chart is part of the legal document of the patient, the complete identity of the patient must be placed since her the entries in those papers concerns the patient Correct inking also presents a way on how to identify the shift that is incharge with the care of the patient and also the time of documentation.

3. Sheets arranged in proper sequence 4. Informed consent for admission/special procedure and treatments are signed by client and/or S.O.

The name of the patient is not stated in the consent for care and surgery and also the designation of the witness is not docuemnted

5. Patients full name recorded on every sheet

Middle initial of the patient is not documented in all of the charts

6. Charting in correct ink color per shift utilized

7. No erasures. Errors drawn through and identified

Nurses notes on PACU to ward is not on correct ink according to the time endorsed to the ward since the nurse used red ink rather than utilizing black ink. On the treatment sheet, doctors Erasures can be a problem in the legal orders and nurses notes documentation since it signifies that the entry of information has been tampered and the one who has signature on this entry is held

8. Correct abbreviations used

Use of CHON for protein and @ instead of admission.

accountable to that data. Also tampering of the data can also be performed by another person whose name is not documented. Abbreviations that are not internationally accepted may present confusion to those who are reading the chart of the patient.

9. Laboratory results attached according to dates DOCTORS ORDERS 1. Doctors orders are legible, dated and signed.

Most of the entries are not legible Medications and other special orders can be mistaken for another since the nurse or doctors cannot easily understand what the entries have been and may have discrepancies in the delivery of care and may compromise health of the patient. Carrying out indicates that the order of the doctor has been performed properly and this prevents confusion and constant asking of everyone who are concerned with the care of the patient. Also this can also be a way on counterchecking the quality of care that is given to the patient.

2. Medications are prescribed in generic 3. Orders are carried out and signed within 1 hour

Carrying out of orders are not done

4. Verbal orders are countersigned by physicians within 30 mins 5. Standing orders are signed within an hour

Carrying out of orders are not done Carrying out indicates that the order of the doctor has been performed properly and this prevents confusion and constant asking of everyone who are concerned with the care of the

6. STAT orders are timed, carried out, charted, and signed within 15-20 mins.

Carrying out of orders are not done

7. Special procedure/referrals are accomplished and noted within the shift

Carrying out of orders are not done such as informing the OR staff and anesthesia prior to the procedure.

patient. Also this can also be a way on counterchecking the quality of care that is given to the patient. Carrying out indicates that the order of the doctor has been performed properly and this prevents confusion and constant asking of everyone who are concerned with the care of the patient. Also this can also be a way on counterchecking the quality of care that is given to the patient. Carrying out indicates that the order of the doctor has been performed properly and this prevents confusion and constant asking of everyone who are concerned with the care of the patient. Also this can also be a way on counterchecking the quality of care that is given to the patient.

C. NURSES NOTES 1. Nurses notes are complete, legible and relevant

2. Notes are signed with designation of nurse stated

History of present illness is not Proper documentation must always be legible and also some of the observed to prevent confusion of data notes are incomplete to the patient and as always noted any pertinent data concerning the patient must always be documented properly since assessment findings are very vital. In some entries the designation This is to check whether the one who of the nurse (year level, staff, signed in the notes are properly PGNT) is not place accountable for their entries especially for students who dont have the license and note on who is the direct superior of the person signing the documentation. Not documented in the chart This can very important since

3. Assessement a. Idiosyncrasies to food,

drugs, substance, etc, are communicated and documented

b. Religious beliefs/ practices on food, treatment, drug, or blood administration noted.

Not documented in the chart

c. General physical and mental condition noted.

Not documented in the chart most of the times.

d. Unusual observations/critical conditions are documented.

Not documented in the chart most of the times.

e. Patients problems identified/ charted.

The A in SOAP charting is not present most of the times.

4. A nursing care plan exists.

Not documented in the chart.

anaphylactic reactions can occur to the patient and present a very grave situation to their health. This is also to notify what substances that are present in the medications can cause idiosyncrasies to the patient. The nursing philosophy believes that quality care must be rendered to all patients regardless of race, creed or situation of life. And what can be integrated in this is the respect to the patients religious concerns since their spirituality is a part of their wellbeing. This presents a quick assessment of the patients status during the shifts and to note changes in the neurosensorium of the patient which always indicates a presence of a grave condition to the patient. This is to back-up the assessment that has been conducted to the patients and can be a source of indirect communication to the physician and tracing the course of the patient in the hospital. This also presents that situation that what is not written is not done. The nursing process is a unique process that enables us to address the needs and problems of the patient. Without identifying the necessary problems of the patient, the plan of care is not well directed and goaloriented. It is always necessary to create a plan and a goal for the shift because it

directs the care of the patient and provides a way on how to evaluate the care rendered if this is effective or not. 5. Nursing actions are documented 6. Effectiveness of nursing actions noted Evaluation is not present in the chart most of the times. This provides an idea to those caring for the client if the identified problem has been properly addressed and solved which can be a source of modification to the plan of the patient.

7. Teaching/discharge plans noted and copy given to patient or family. TOTAL SCORE 5

2 2

Summary From what can be evaluated in the chart of the client we can see that proper documentation has not been well observed considering the fact that the chart of the patient is a legal document. FORMAT: Sequencing of pages and laboratory results were the only parts that were properly observed. What can be noted is that proper identification of the patient in the charts is not well observed. DOCTORS ORDERS: The only appropriate in these documents were the use of generic drugs which can be noted on the generics drug act. It can be observed that carrying out of the orders cannot be assessed since it is not signed by the nurses on duty. NURSE NOTES: Problems concerning correct documentation is not well observed and discrepancies are at a voluminous state. Conclusion: What can be concluded in this auditing is that the discrepancies arise when the accountability of the person writing on the chart was not well taken into consideration Also proper identification is poorly observed since it is a necessity to properly identify the patient in her chart. Concerns regarding the proper documentation of the ADPIE process is also evident, it was as if this process was also taken for granted and quality of care is not met to tis optimum state. We must always take into consideration that the identity of the nursing process is through the process of ADPIE. Recommendation: What can be recommended in this concurrent nursing audit is that proper accountability must be observed since all entries in this legal document is considered as correct and implicated. Though it is a bit too paperwork oriented we must still devote sometime in this since what we are all doing to our patients are only considered when they are properly documented and communicated. Hence through this we can enhance patient satisfaction through efficient nursing work and proper communications.

NOTED: Vanessa M. Tuban Name and Signature of Clinical Instructor Gerald T. Pagaling

AUDITED BY:

Name and Signature of Student Nurse

Saint Louis University School of Nursing Baguio City

Concurrent Nursing Audit As a partial requirement for: Benguet General Hospital Surgery Ward September 1-3, 8-10 2011

Submitted to: Mrs. Vanessa M. Tuban, RN

Submitted by: Gerald T. Pagaling

September 10, 2011