Invasive Procedure Audit
AdHoc form in Cerner used to complete invasive line documentation after a procedure
What is the Post Procedure Summary Note?
What is needed before the start of any sedation procedure?
What is a Patient Consent Form?
Must be done at point of triage for all patients.
What is the Columbia Suicide Severity Rating Scale (C-SSRS)
This must always be completed before antibiotic are hung or a patient?
What is Blood culture draw x2?
An ED event note must be documented at least every shift in order to ensure that family is aware of the patient condition
What is family plan of care updates?
Form used for all central line insertions
What is the Central Line Insertion Practices Adherence Monitoring (CLIP) Form?
This form is required for patients 14 years and older prior to sedation begin (AdHoc Forms and Pre-Op Checklist are examples of where this form can be found)
What is the STOP-BANG Form?
Must be done once by the bedside RN at time of initial assessment. hint: 2 parts to this answer
What is the Columbia Suicide Rating Sale Risk Assessment and SI plan of care?
Always make sure you have this before putting anyone in restraints
What is a physician order?
This is required for a new prescribed mediations at discharge
What is MedUcation for each new med?
Must be documented after an invasive procedure is complete in the additional information free text box
What is "visualization of all surgical items"?
An assessment done Pre and Post Sedation to determine if a patient is safe for discharge from the ED.
What is an Aldrete Score?
This must be started within 15 mins from the time the Columbia Suicide Severity Rating Scale is completed with a moderate to high score
What is the Suicide Precaution Observation Checklist? (this is still on paper)
Must document observation and interventions every 2 hours for this type.
What is a non-violent restraint?
This must be charted prior to starting a Fentanyl drip, with start or titration and at a minimum of every hour when not titrating.
What is a complete CPOT score?
All patient receiving an invasive procedure must have a sticker placed here
what is the Invasive Line Report Log?
The three assessment requirements needed Q 5mins during sedation procedure and Q 15min during sedation recovery.
What are vital signs, ETCO2, and RASS or Comfort B (depending on age)?
A moderate or high rate in the Columbia Suicide Severity Rating Scale requires this frequency of patient check
What is every 15 min observation checks?
Documentation required within the hour after a fluid bolus is completed to assess for persistent hypotension.
What is two complete sets of vital signs with BP (to determine if pressors are needed)?
Reassessment needed for all patients receiving OPIOID pain medication within 15 mins for IV and 30 mins IM or PO meds
What is POSS (Pasero Opioid Sedation Scale)?
Central Line insertion; Pacer or Chest Tube insertion; Paracentesis; Lumbar Puncture and I & D are all examples of what?
What is an "Invasive" Procedure?
NPO status; Emergency Equipment available; Verified ID with 2 identifiers; Procedure Confirmed are all key requirements of this.
What is a Procedural Timeout?
What is safety attendant, direct observation, safe environment?
Must be initiated when placing a patient in restraints; if Braden score is 13 or less; and during the next shift after admit.
What is a Plan of Care?
The form that must be completed by the nurse answering a call from lab about abnormal lab values.
What is the Critical Value Result Note in AdHoc?