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 f/u if a referral was triggered. Where is your nutritional assessment?

Have staff show dietitian’s f/u if a referral was triggered.

What would precipitate a social work referral? Nurse verbalized indications for social work referral

Have staff show social worker’s f/u if a referral was triggered

Does this patient have advance directives? Where is it documented?
Is a copy of the document in the medical record? Nurse said patient has an advance directive but did not bring it with her.
Family was reminded a copy was needed but failed to bring in.

If patient does not have Advance Directive, was information provided?

What are the patient’s allergies?

No allergies

Note allergies on all documents where they are documented (ie, H&P, ED, MAR) and whether all sources agree.

Does this patient have any cultural/ spiritual needs?

Priority Focus Areas (PFA) Addressed:
 Assessment & Care/Services
Communication
Credentialed/Privileged Practitioners
Equipment Use
 Infection Control
Information Mgmt
 Medication Mgmt
Organization Structure

Orientation & Training
 Rights & Ethics
Physical Environment
 Quality Improvement
 Patient Safety
Staffing

Coach staff to avoid responses with
“usually”, “sometimes,” and other descriptions that could indicate that the practice is not consistent.

Questions / Actions
Is this patient at risk for skin breakdown problems? Where is it documented?
What breakdown prevention measures are taken? Notes/Deficiencies Identified

Is this patient at risk for falls?
Where is it documented?
How is the risk for falls communicated shift to shift? Dept to dept?
What precautions have been implemented for this patient?

Yes. Documented in the nursing admission assessment. Fall risk is included in handoff form.
Precautions: slip proof socks, night light Does this patient have a plan of care?
How are care plans updated or changed?
How do all disciplines come together for a plan of care?

Initial nursing plan of care documented but not updated since surgery. Interdisciplinary Rounds (IDR) or Caring
Rounds
Are IDR documented?
Are