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CQI Process Model

13 Elements to Quality Patient Care

CCR Information:

Documentation Do's & Don'ts:

Documentation of: Do's Don'ts
Vitals
  • Multiple sets when needed
  • Pressures without at least one baseline, full pressure
  • Take only palpation
Medications
  • List all meds taken by patient
  • Leave spot on report blank
  • Use "see list" without attaching a copy of the actual list
Allergies
  • List all allergies including non-med allergies
  • If patient has allergies list side effect and sensitivities etc.
  • Leave spot on report blank
  • Use "see list" without attaching a copy of the actual list
PMH
  • List all medical history even if it does not appear to be relevant to the current event
  • Leave spot blank on report
  • Use abbreviations unless they are commonly accepted and known by all healthcare providers
  • Leave out some items that you do not think are relevant to the current problem
Times Recorded in Flow Chart
  • List times for each set of vitals, med administration, skill or procedure performed
  • Leave times missing or only enter some times
Name of Medical Control Physician
  • Give name of physician spoken to for on-line medical direction or put "Standing Orders" for off-line medical direction
  • Leave spot on report blank
  • Use terms such as "ER doctor"
Stroke Protocol
  • Document a thorough neuro exam
  • Perform the Boston Stroke Scale
  • Document that the entry note nurse was advised that this patient warranted activation of the stroke team upon arrival to ED.
  • Forget to activate the stroke team
12 Lead EKG
  • Perform a 12 lead on any patient suspected of having a cardiac event
  • Attach all 2 lead and 12 lead strips to run report and QA copy of run report.
  • Perform on diabetics with vague complaints
  • Label with patient name, date etc.
  • Forget to attach a copy of strips and 12 leads to QA copy of run report as well as copy left at facility
  • Write 12 lead performed without attaching a copy
DNR
  • Document contact with medical control for all DNR patients who are not treated to protocol
  • Attach copy of DNR order to both run report and QA copy of run report
  • Forget to attach copy of DNR to run report and QA copy of run report
Blood Glucose
  • A B.G. on all altered mental status patients or diabetics who exhibit other complaints that could mask a hypoglycemic episode
  • Document B.G. clearly on run report
  • Remember to provide a before and after B.G. for suspected hypoglycemic patients
  • Forget to document B.G.
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