Surgical Patient Tracer Worksheet
Nightingale Community Hospital – in Year 2 of Audit Cycle
Admission/Service Start Date:___________
Sequence of Care/Services
Admitted with post-op wound
Went to surgery for drainage
Long term antibiotics
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
Does the staff member know the course of
Show me the patient’s admission
assessment (or initial nursing assessment).
When is the assessment done?
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
Ask about med reconciliation process
How is care plan generated?
Describe the medication reconciliation
Primary nurse able to verbalize med
Review of chart had evidence of med
reconciliation on admission and after
Where is your functional assessment?
What precipitates PT, OT, or SLP referral?
Function assessment triggered based
on admission assessment but no
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
Med Recon is done at discharge—any
discrepancies and nurse can hold up
Have staff show...