Chart/ Room audit items | Response |
---|---|
Cognition | |
Was the patient’s cognitive functioning assessed using a standardized assessment tool (e.g. MSQ, MMSE) within 24 h of the patient’s admission to the ward? | Yes/ No |
Was the patient’s cognitive functioning assessed informally (i.e. not using a standardised assessment tool). Comments may include ‘oriented to person, time, place’ or ‘memory OK etc.’ | Yes/ No |
Pain Assessment and Management | |
Was a pain assessment undertaken within the last 24 h/ since the last observation? | Yes/ No |
Was analgesia administered within the last 24 h/ since the last observation? | Yes/ No |
Medication Use | |
Was antipsychotic medication administered to the patient within the last 24 h/ since the last observation? | Yes/ No |
Was benzodiazepine medication administered to the patient within the last 24 h/ since the last observation? | Yes/ No |
Items requiring direct observation | Response |
Behavior | |
Did the patient display symptoms of agitation (e.g. moaning, calling out, pacing, fidgeting, hand wringing etc.) OR pain OR discomfort (e.g. frowning, grimacing, holding onto any part of his/ her body, crying or moaning etc.)? | Yes/ No/ N/Ab |
What was the patient doing at the time of the observation? | Various, e.g. Asleep/ Lying in bed – no activity – engaged in activity / Sitting in chair |
Orientation | |
Did the nurse address the patient by name when he/ she interacted with the patient? | Yes/ No / N/A |
Did the nurse introduce themselves when they interacted with the patient? | Yes/ No/ N/A |
Did the nurse re-orient the patient if confusion/dis-orientation was evident? | Yes/ No / N/A |
Communication | |
Did the nurse explain the activity/ procedure in easy-to-understand terms to the patient? | Yes/ No / N/A |
Nutrition Was adequate assistance provided to the patient if the patient had difficulty eating or drinking during meal-times? | Yes/ No / N/A |