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 Date
1._Surgical Nursing Unit__________
2. _Radiology_______________________
3. _OR_____________________________
4. _PACU__________________________
Current Location _Surgical Nsg Unit ___
Admitting/Presenting Dx/Condition:
Admitted with post-op wound
infection
Went to surgery for drainage
Long term antibiotics
Supportive spouse
Plan home health at discharge
Questions / Actions Notes/Deficiencies Identified Tracer Tips
Ask the staff member to give you a report on the patient like he/she may give to an oncoming shift.
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
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
Where is your functional assessment? OR What precipitates PT, OT, or SLP referral?
Function assessment triggered based
on admission assessment but no
documentation found
Have staff show f/u if a referral was triggered.
Where is your nutritional assessment?
Nutritional assessment documented 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?
Coach staff to avoid responses with “usually”, “sometimes,” and other descriptions that could indicate that the practice is not consistent.
Priority Focus Areas (PFA) Addressed: Assessment & Care/Services Orientation & Training Communication Rights & Ethics
Credentialed/Privileged Practitioners Physical Environment
Equipment Use Quality Improvement Infection Control Patient Safety
Information Mgmt Staffing Medication Mgmt
Organization Structure
Surgical Patient
Questions / Actions Notes/Deficiencies Identified Tracer Tips
Is this patient at risk for skin breakdown problems? Where is it documented? What breakdown prevention measures are taken?
Yes due to infection and poor
nutritional intake. Skin assessment
done on admission. Patient on
specialty bed
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 care plans reviewed daily? And updated?
What type of patient education has the patient received and where is it documented? Where are the patient’s educational needs assessed? Does this patient have any barriers to learning? How does this patient learn best? How do you know if patient understands the education provided?
No barriers to learning identified.
Patient education has been on-going
since admission.
With husband’s assistance, patient
has demonstrated central line
dressing change.
On inpatient units, nurse should go to Meditech and pull up documentation Also check discharge instruction sheet. Educational assessment, preferences and learning needs should be in Meditech
What is the discharge plan? Where is the discharge plan documented?
Home with home health
How do you communicate patient info among disciplines?
Interdisciplinary progress notes and
1:1
What is your policy for pain assessment? Show me the pain documentation in this chart. Do you use pain scales? How would you assess for pain in a non-verbal patient (infant, child, adult)? How do you document effectiveness of pain treatment? What is the time frame for reassessment? How do you educate patients about pain?
Pain assessed at least every 4 hours.
Uses 0-10 pain scale.
When pain med given, supposed to
check on effect within 1 hour but
documentation was > 1 hour the last
4 times.
Documentation found should correspond with pain assessment policy. Look for pain assessments with reports of moderate or severe pain (4-5 or above) and ask if treatment was given. If no treatment, why not? If treatment given, how does nurse know if it was effective? Find pain med administration on MAR and ask nurse to show the pain reassessment.
Environment of Care—for example: Storage of oxygen tanks Code Carts Overall cleanliness Hallway clutter
Oxygen tanks found on floor and not
secured
Air vents dusty in clean utility room
and patient room
Oxygen tanks need to be stored in secure stands Code carts require checks every shift
What is the process for taking a telephone or verbal order? Do you ever take verbal orders face-to-face?
Nurse described process using “repeat
back”—reviewed proper process of
writing down the MDs order and then
repeating back to MD
Looking for statement regarding read-back. Staff should not say repeat back. Looking for nurse to say that he/she would ask the MD to write the order if face-to-face.
Do you receive calls with critical values or test results? What do you do when you receive a call about critical values? How do you document critical values?
Did not use “read back” process when
describing receipt of critical values.
Looking for statement regarding read back. Document in MD Notification screen
What are the 2 identifiers that you use to identify patients prior to administering medications and blood?
Nurse verbalized “Name and Medical
Record #”
Name and MR#
Questions / Actions Notes/Deficiencies Identified Tracer Tips
What do you do if a physician writes an order with one of the unacceptable abbreviations?
Call him and clarify order. Rewrite
verbal order without abbreviation
Examine physician orders. Incomplete orders—call physician and
request missing part of order.
Follow up on any order that is not complete or would require judgment (e.g., titrate to BP> 60, administer slowly, taper, etc.) Ask staff what action would be taken for illegible or incomplete order.
What is your policy for range orders? Nurse not able to explain range order
policy. When asked what she would
give if range was 25mg-100mg, she
answered 100mg.
For any range order found, ask staff member how he/she would implement the order.
How is DNR status communicated and documented?
Patient would wear a purple arm
band.
Did this patient receive blood? What is your process for blood administration? What do you do if patient has a reaction to transfusion? (ie spikes temperature)
Yes. Blood consent signed and on
chart. Blood double checked with
another RN.
Examine blood administration documents for completeness.
Is there a standard communication method that you use when you are giving report or calling a physician about a patient?
Try to do rounds at bedside when
possible. Uses SBAR when calling
MD.
Response should refer to SBAR
Describe hand off process (ie, from PACU to floor or ICU to floor)
Disjointed hand-off process,
inconsistent use of handoff form
Response should refer to handoff form.
What are PI projects in progress that pertain to your area?
Fall prevention
SDS /
Questions / Actions Notes/Deficiencies Identified Tracer Tips
What is your process for informed consent?
Signed prior to sedation given. No
abbreviations allowed.
Examine any informed consents in the record for completion and agreement with process stated by staff member.
Who marks side/site? How is the site marked? When is the site marked?
surgeon marks the site with his
initials, usually in SDS pre-op area
but always before taken to OR
Surgeon marks the site with his initials before the patient goes to the OR/procedure room
Regional Blocks– Who marks the site? Do you do a time out?
Anesthesia marks the site Site should be marked by anesthesiologist and time out should be done
Do you do time outs? When is the time out done? Who is present for time out?
Yes, when we do regional blocks—and
it is done immediately prior to
sticking patient. The nurse,
anesthesiologist and patient are
included in the time out.
Give me an example when you would use override (Pyxis).
Only in urgent situations. Override is used in urgent/emergent situations. The situation, not the medication determines if override is appropriate.
Is there a standard communication method that you use when you are giving report or calling a physician about a patient?
SBAR Response should refer to SBAR
Show me the pre-op checklist and describe process
SDS nurse completes and is available
for 1:1 with OR nurse if questions
arise.
OR Nurse
Questions / Actions Notes/Deficiencies Identified Tracer Tips
What is your process for informed consent?
Surgeon explains the surgery risks,
benefits, and alternatives. Nurse
“witnesses” the patient’s signature.
Any questions—nurse contacts the
surgeon to answer.
Examine any informed consents in the record for completion and agreement with process stated by staff member.
Who marks side/site? How is the site marked? When is the site marked?
Surgeon marks the site before patient
gets to OR.
Surgeon marks the site with his initials before the patient goes to the OR/procedure room
Where is the time out documented? When is the time out done? Who is present for time out?
Documented in the intraoperative
nursing record
Time out done immediately prior to
incision
Nurse named all but anesthesia
provider
Response should indicate time out is done immediately before start of procedure and that all members involved in procedure are present—including the physician and anesthesiologist.
Medication labeling— Who labels medications that are used during surgery? Describe process for labeling
Circulator labels meds when they are
drawn up. All containers are labeled
too.
Label one at a time, at the time the med is prepared/poured. Containers must be labeled. Original container should not leave the room or be discarded until case is over.
PACU Nurse
Questions / Actions Notes/Deficiencies Identified Tracer Tips
Give me an example when you would use override (Pyxis).
To get anti-nausea drugs for patients
when they return from surgery
Override is used in urgent/emergent situations. The situation, not the medication determines if override is appropriate.
What is your policy for range orders? Start with the lowest dose ordered and
work up if necessary
For any range order found, ask staff member how he/she would implement the order.
Describe how you assess the post op patient for pain and how you determine what/when to give. Do you use pain scales? How would you assess for pain in a non-verbal patient (infant, child, adult)? How do you document effectiveness of pain treatment? What is the time frame for reassessment?
Usually assess pain by patient’s
facial expressions and behavior since
they are coming out of anesthesia.
Once more awake, will use 0-10 scale.
Reassessment done within 1 hour or
sooner and prior to any other pain
med being given.
