ICU Documentation Audit 2016
Please contact Jason Fletcher or Jenni Tuena for any queries.
This audit is applied to every HDU or ICU patient in the unit on the day of audit. It does not include CCU patients.
Each patient should be audited and their data entered individually.
The data for each calendar month will be collated and reported at the next ICU M&M by the ICU registrar.
Date of audit *
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/
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YYYY
1. Weight documented on each drug chart *
Required
2. Patient sticker on each drug chart *
3. Each drug has an indication documented ('usual medication' is insufficient) *
4. Drug chart is LEGIBLE *
5. Each drug that is ceased must be signed, dated and the reason for cessation documented e.g. dose changed, course completed, ceased *
6. IV fluid orders are signed and there is documentation of rate and time commenced ('APP' for drugs titrated by RNs is acceptable). (Both nursing and medical components checked) *
7. Ward round notes document: date, time, consultant name, and signature and designation of documenting doctor *
8. Daily review completed, includes: issue list, examination and plan *
9. Parent unit notes document: date, time, consultant name, and signature and designation of documenting doctor *
10. Has every progress note sheet have a patient sticker present (back and front)? *
11. MR85 form completed appropriately, including identifying the responsible consultant *
12. PFM (Patient Flow Manager) updated with resuscitation plan (even if for full resuscitation) *
13. Weight documented DAILY on the ICU observation chart (nursing responsibility) *
14. CAM-ICU is documented by the ICU doctor in the daily review *
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