aft task 3

aft task 3

  • Submitted By: agaspa2
  • Date Submitted: 08/29/2016 7:18 PM
  • Category: Science
  • Words: 1974
  • Page: 8

Surgical Patient

Surgical Patient Tracer Worksheet
Nightingale Community Hospital – in Year 2 of Audit Cycle

Admission/Service Start Date:___________
Tracer Surveyor(s):

Sequence of Care/Services


Admitting/Presenting Dx/Condition:

Nursing Unit__________

2. _Radiology_______________________
3. _OR_____________________________
4. _PACU__________________________

Admitted with post-op wound
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

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
Ask about med reconciliation process
How is care plan generated?

Describe the medication reconciliation

Primary nurse able to verbalize med
reconciliation process.
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
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
Have staff show...

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