SECTION 2: ADMISSION & RISK ASSESSMENT AUDIT INDICATORS

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1 AUDIT INDICATORS Each record should be audited against each question. Where the record does not contain the required elements for audit, instructions are given below. Question 1 should be completed for all records. For further explanation of the audit indicators please refer to Glossary of Terms, Explanatory tes for Audit Indicators and Frequently Asked Questions. 1. The patient s admission documentation shows a written record of: a. Full Name b. Home Address c. Contact Telephone d. Date of Birth e. Religious Beliefs f. Next of Kin/other to notify in the event of emergency g. First Language/Communication needs h. General Practitioner i. Admitting Consultant j. Admitting Nurse k. Main reason for the patient s admission l. Time of admission m. Date of admission n. Height o. Weight p. Physical disability q. Past medical history r. Allergy status s. Blood pressure t. Pulse u. Respiration rate v. Temperature w. Mental/emotional state x. Patient skin integrity y. Patient normal urinary habit z. Patient normal bowel habit aa. Admission urinalysis bb. Sleep pattern cc. Braden Score dd. Must assessment ee. Moving and handing assessment ff. Infection control assessment gg. EWS assessment hh. A judgement of whether or not the patient is at risk of falling Copyright rthern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC)

2 AUDIT INDICATORS The patient has been judged to be at risk of falling. complete Question 2 Go to Question 3 2. The patient s admission documentation shows a written record of: a. A falls assessment has been carried out? The patient has relevant items of property which must be recorded as per trust policy. complete Question 3 Go to Question 4 3. The patient s admission documentation shows a written record of: a. Relevant items of property as per trust policy The patient has external aids (including dentures, hearings aids etc). complete Question 4 Go to Question 5 4. The patient s admission documentation shows a written record of: a. External aids (including dentures, hearing aids etc) Is the patient female? complete Question 5 This section is complete go to Section 3 5. The patient s admission documentation shows a written record of: a. Menstrual history Copyright rthern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC)

3 ORGANISATION SECTION 2: ADMISSION & RISK ASSESSMENT AUDIT 1. The patient s admission documentation shows a written record of: a. Full name b. Home Address c. Contact telephone no d. Date of birth e. Religious Beliefs f. Next of Kin/other to notify in the event of emergency g. First language/communication needs h. General practitioner i. Admitting Consultant j. Admitting Nurse k. Main reason for the patient s admission l. Time of admission m. Date of admission n. Height o. Weight p. Physical disability q. Past medical history r. Allergy status s. Blood pressure t. Pulse u. Respiration rate Copyright rthern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC)

4 ORGANISATION AUDIT 1. The patient s admission documentation shows a written record of: v. Temperature w. Mental/emotional state x. Patient skin integrity y. Patient normal urinary habit z. Patient normal bowel habit aa. Admission urinalysis bb. Sleep Pattern cc. Braden score dd. Must assessment ee. Moving and handling assessment ff. Infection control assessment gg. EWS assessment hh. A judgement of whether or not the patient is at risk of falling 2. The patient s admission documentation shows a written record of: a. A falls assessment has been carried out? 3. The patient s admission documentation shows a written record of: a. Relevant items of property as per trust policy? Copyright rthern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC)

5 ORGANISATION AUDIT 4. The patient s admission documentation shows a written record of: a. External aids (including dentures, hearing aids etc)? 5. The patient s admission documentation shows a written record of: a. Menstrual history? Copyright rthern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC)

6 ORGANISATION SECTION 2: ADMISSION & RISK ASSESSMENT SCORE SHEET Question Number a b c d e f g h i j k l m n o p q r s t u v w x y z aa bb cc dd ee ff gg hh TOTAL Average Score TOTALS YES Question Number 1 Admission Documentation 2 Falls Assessment 3 Relevant items of property 4 External aids 5 Menstrual history TOTALS Section Audit Results Copyright rthern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC) 5 5 5

7 PERCENTAGE KEY 0 RECORD RELEVANT Disregard this question for the audit. 1 RECORD RELEVANT Where only one record has the relevant information: Scoring = 100 Scoring = RECORDS RELEVANT Where only two records have the relevant information: 1/2 = 50 2/2 = RECORDS RELEVANT Where only three records have the relevant information: 1/3 = /3 = /3 = RECORDS RELEVANT Where only four records have the relevant information: 1/4 = 25 2/4 = 50 3/4 = 75 4/4 = RECORDS RELEVANT Where all five records have the relevant information: 1/5 = 20 2/5 = 40 3/5 = 60 4/5 = 80 5/5 = 100 Copyright rthern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC)

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