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...