Nursing Home Unit Audit Tool

Nursing Home Unit Audit Tool

Nursing Home Unit Audit Tool
This audit tool evaluates documentation practices, technology use, and hospital culture in a nursing home unit. This tool focuses on four themes: initial patient assessment, subsequent management, technology and culture, and discharge.
Name of the auditor:	Date:
Contact information:
Initial Patient Assessment
The patient’s name or initials are present		Yes			No
The facility’s number is present		Yes			No
Records indicate referral source (where applicable)		Yes			No
The date and time are present		Yes			No
The impression or working diagnosis is present		Yes			No
Investigations and findings are present		Yes			No
The treatment plan is present		Yes			No
Food and drug allergies are recorded		Yes			No
Total points deducted
Subsequent Management
The facility has an elaborate approach to promoting accurate patient identification.			Yes			No
The facility has a policy for retaining and disposing of medical records			Yes			No
The facility has an elaborate policy for informed consent for patients receiving various treatments.			Yes			No
Interventions are recorded and updated daily. The name of the clinician making these interventions is present.			Yes			No
Treatment plans are updated daily based on the patient’s progress.			Yes			No
The nutritional status and dietary needs of each patient are captured.			Yes			No
The facility upholds patient data privacy, confidentiality, and security.			Yes			No
Total points deducted
Technology and Culture
The facility has embraced the electronic health record system to optimize documentation.				Yes			No
The facility has leveraged barcoding to promote accurate patient identification.				Yes			No
The facility has leveraged technology such as smart infusion pumps (or any other technology) to minimize medical errors.				Yes			No
Culturally sensitive services are provided.				Yes			No
Total points deducted
Patient Discharge
The name and address of the patient are indicated.			Yes			No
The dates of admission and discharge are indicated.			Yes			No
The name of the discharging clinician is present.			Yes			No
The patient’s diagnosis is present.			Yes			No
The investigations (laboratory and radiological) and results are present.			Yes			No
Interventions and treatment given are present.			Yes			No
Any complications, toxicities, or hypersensitive reactions during hospitalization are recorded.			Yes			No
Medication on discharge is indicated.			Yes			No
Follow-up instructions are present.			Yes			No
ICD number is indicated.			Yes			No
Patients who leave against medical advice have consented to treatment refusal.			Yes			No
Total points deducted

Darghahi et al. (2019) report that an audit tool enables stakeholders to identify key aspects that should be modified or changed to improve the quality of service delivery. In the healthcare sector, auditing provides an opportunity to optimize a facility’s structure, processes, and outcomes. As such, periodic audits should be conducted to direct the formation of informed decisions when developing a quality improvement program. This paper evaluates an auditing tool for a nursing home unit.

This audit tool evaluates documentation practices, technology use, and hospital culture in a nursing home unit. It focuses on four themes: initial patient assessment, subsequent management, technology and culture, and discharge. The four themes address thirty aspects of the nursing home. As such, the cumulative points are thirty. The initial patient assessment addresses eight aspects, whereas seven points are addressed in subsequent management. Technology and culture address four points, whereas discharge addresses eleven points. The auditor will award one point if each criterion obtains a “yes” response.

The initial patient assessment documents history taking, investigations, diagnosis, and interventions. This section checks medical records to ensure that they fulfill the specified criteria. The evaluation focuses on the presence of a patient’s name or initials, the facility’s number, referral source, date and time of admission, the impression, investigations and findings, and the treatment plan. Furthermore, medical records are checked to ascertain whether food and drug allergies have been indicated.

Subsequent management focuses on patient care after admission. In this section, the auditor will evaluate various aspects. They include an identification system, a policy for retaining and disposing of medical records, and an informed consent policy. Also, the auditor will check whether or not interventions are recorded and updated daily, whether treatment plans are updated daily, and whether nutritional statuses and needs are captured. Furthermore, the auditor will evaluate whether the facility upholds patients’ privacy and confidentiality.

Technology and culture will focus on the use of healthcare technology and the presence of cultural congruence. Healthcare technology optimizes the quality of care. Notably, barcodes and smart infusion pumps improve patient identification and promote safe medication administration (Michalek & Carson, 2020). Furthermore, electronic health record systems eliminate unnecessary paperwork, optimize documentation, and minimize medical errors (Bloom et al., 2021). Cultural congruence promotes holistic care by acknowledging and respecting diverse preferences among patients.

Finally, patient discharge will focus on the documentation of various aspects. Examples of these aspects include the patient’s name, admission, discharge dates, the name of the discharging clinician, and the patient’s diagnosis. The other aspects include laboratory or radiological investigations, interventions, complications or toxicities, medication on discharge, and follow-up instructions. Furthermore, this section will check for consent to refuse treatment and the ICD number.

References

Bloom, B. M., Pott, J., Thomas, S., Gaunt, D. R., & Hughes, T. C. (2021). Usability of electronic health record systems in UK EDs. Emergency Medicine Journal, 38(6), 410–415. https://doi.org/10.1136/emermed-2020-210401

Darghahi, H., Irandoust, K., & Mojtabayan, S. M. (2019). Evaluating the readiness of selected hospitals of Tehran University of Medical Sciences to implement a clinical audit program from the viewpoint of hospital managers in 2018. Journal of Hospital, 18(2), 101-111. http://jhosp.tums.ac.ir/article-1-6074-en.html

Michalek, C., & Carson, S. L. (2020). Implementing barcode medication administration and smart infusion pumps is just the beginning of the safety journey to prevent administration errors. Farmacia Hospitalaria, 44(3), 114–121. https://doi.org/10.7399/fh.11410

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In order to identify opportunities for improvement, as well as to meet and exceed regulatory requirements in any healthcare organization, auditing and monitoring are essential components of the Quality Improvement Program. It is your turn to develop an audit tool to assess a medical record or to conduct observational rounds (examples: hospital floor, Nursing Home Unit, Clinic, Urgent Care Center). The criteria to be included would be the title of the audit tool, the date, and the auditor’s name, and you will determine the rest.