Priority Focus Audit Form:

Invasive Procedures

Unit: ________________________________Date:_______________________________________
Not Comments
Met Partial N/
Invasive Procedures Met A
2 1
0
ssProcessionAdmi

Chart audit, interview with staff,

competencies, and observation
Ask care provider to describe the pre-admission
process (as applicable)
Is the H & P present on the chart within 24
hours of admission or sooner if surgery/invasive
procedure is scheduled?
H & P performed by non SNH Physician. Is
second assessment documented on admission by
member of SNH Professional Staff?
If H & P performed prior to admission, chart
contains update note (changes in systems or
documentation that no change occurred) prior to
surgery/invasive procedure.
Does this patient have an Advance Directives?
If yes, is the document available in scan view
and is the lavender banner visible?
Pre Procedure

.pre op note done within 24 hours of surgery

Consent is accurate, signed and dated within 30
days of procedure
Blood consent signed and dated if applicable
Patient is determined to be an appropriate
candidate for anesthesia
Prior to the procedure, plan for nursing care is
documented
Pre-op plan for anesthesia is documented
Describe the “hand off” process from the unit to
the holding area
Provisional diagnosis is recorded prior to IM.6.30 EP 1
procedure
What two unique identifiers are used to verify
correct patient?
Results of indicated diagnostic tests are recorded IM.6.30 EP 10
before the procedure
Is the site marked by MD (initials mark the site)
when appropriate?
Learning needs identified?
Look-alike, sound-alike medications are
segregated to avoid confusion (LASA list posted
on unit) by Accudose
Nurse obtained list of home medications from
the patient
Process for safely managing high-alert or high-
risk medication is evident (independent double-
check being done before administration of
med?)
Nurse can articulate how range orders are
utilized.
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Is pre op checklist utilized, completed?
Process for controlled substance waste evident
and MD doc matches MAR
Medications are properly and safely stored
Patient confidentiality protected.
Immediately prior to induction or moderate PC.13.20 EP 12 (A)
sedation, patient is re-evaluated
Appropriate hand washing noted.
Intra Procedure

No unlabeled medications on anesthesia cart

Syringes, basins etc are appropriately labeled on
and off the sterile field
Explain the process for verifying the count is
correct
If preop antibiotic is ordered, is it given within
60 minutes prior to incision?
Medications are labeled appropriately on sterile
field with drug and strength
Proper attire (hair covered completely, no
jewelry, PPE in place)
Site is marked
Observe a “time out”. Are all elements
included? List them
Prep done in sterile fashion
How is the “handoff “performed when you
move your patient to another level of care
No artificial nails
Post Procedure

Is the post op note done prior to moving to

another level of care? Does the note address the
following:
• Procedure
• Name of surgeon and assistant
• Findings
• Specimen(s) removed
• Pre-op diagnosis
• Post-op Diagnosis
• Estimated blood loss
• Signature of surgeon
No unapproved abbreviations in charting.
Sterilizer documentation complete

Postoperative documentation records the name IM.6.30 EP 8

of the licensed independent practitioner
responsible for discharge
Pain documented per policy.

Postoperative documentation records IM.6.30 EP 5

♦ Patient’s vital signs and level
of consciousness &
♦ Medications (including
intravenous fluids) IM.6.30 EP 6
♦ Blood and blood components
 Priority Focus Audit Form: Invasive Procedures Page 3 of 4
administered
♦ Unusual events or
complications, including blood
transfusions

Patient discharged from PACU by licensed IM.6.30 EP 7

independent practitioner or according to
discharge criteria.
The use of approved discharge criteria to
determine the patient’s readiness for discharge is
documented in the medical record
How is the “hand off” performed when you
move your patient to another level of care
Environment of care

Proper storage and maintenance of X-ray gowns

Refrigerator logs up to date

Crash cart logs up to date, no expired product
No expired product on unit
What is your process for taking broken
equipment out of service?
Who is in charge of an oxygen valve shut off
during a fire?
Hallways are clear for egress with items stored
on one side
Staff Education

What is your role in a fire

What is R.A. C. E.?
How are you determined competent to do your
job?
What does MSDS stand for and how do you find
information? Where is the MSDS information
for SNH?
How do you verify a physician’s privileges?
What is the hospitals mission?
How does SNH provide assistance with ethical
concerns?
How to you report adverse events or unexpected
outcomes
Has new equipment been purchased this year
and how were you trained?
Performance Improvement

What PI data is your unit collecting? What are

the findings?
What improvements has your department made
this past year?

Request HR file of surgical nurse. Check for

evidence of surgical fire training/competency.
Is “time out” process part of competency list
Request evidence in file the scrub nurse and
circulating nurse has been trained on the new
 Priority Focus Audit Form: Invasive Procedures Page 4 of 4

Human Resources
count verification process in 2007

Nurses file in Same Day Surgery. Check for

education on hand off communication and
medication reconciliation.

PACU nurse file. Check for hand off

communication training.