2. PEDIATRICS EMERGENCY - AMBULATORY PATIENTS
OPERATIONAL PROCESS AUDIT REPORT
GENERAL INFORMATION REMARK
Total cases seen over 24 hrs
Total number of deaths over 24 hrs
Senior round AM PM
MRN
Disposed
physician
Time
triage
to
visit
Physician documentation
Visit
Diagnosis
Investigation
Management
(all
required)
789541 Sumeya Ali
721746 Dr Remla M
789546 Dr Meron D
789573 Yusra Jemal
3. PEDIATRICS EMERGENCY - PREVIOUSLY KEPT PATIENTS
OPERATIONAL PROCESS AUDIT REPORT
MRN Physician
documentation
Nursing documentation of the day Clinical
pharmacy
documentation
REMARK
Progress
note
Order
sheet
Nursing
progress
V/S
Medication
sheet
Follow
up
chart
Nursing
care
(if
applicable)
Pharmaceutical
progress
daily
788991 NA
789130 NA
4. MRN Physician documentation Clinical pharmacy documentation REMARK
Progress
note
Order
sheet
Clinical audit
Remarks on the progress note
and management plan
Medication
profile
Medication
reconciliation
Pharmaceutical
progress daily
788635 CLIN.PHARM EVALUATION DAILY
788924 ORDER DAILY
786179 CLIN.PHARM EVALUATION DAILY
769716
PREVIOUSLY ADMITTED PATIENTS AUDIT TOOL
WARD NAME………PED A………… previously Admitted pts _____25_____ Total pts
Sampling method
•Previous admissions - Total chart to be audited (N) = 15% of total patients (5 if 30 beds, 3 if 10 beds)
Sampling : Lottery method for 1st MRN from 1 to N -> every Nth (As per the order on the automation)
5. MRN Physician documentation Clinical pharmacy documentation REMARK
Progress
note
Order
sheet
Clinical audit
Remarks on the progress note
and management plan
Medication
profile
Medication
reconciliation
Pharmaceutical
progress daily
771222 NA NA NA
788489 PROGRESS AT LEAST DAILY NA NA NA
PREVIOUSLY ADMITTED PATIENTS AUDIT TOOL
WARD NAME………PED BURN…………previously Admitted pts _____6_____ Total pts
Sampling method
•Previous admissions - Total chart to be audited (N) = 15% of total patients (5 if 30 beds, 3 if 10 beds)
Sampling : Lottery method for 1st MRN from 1 to N -> every Nth (As per the order on the automation)
6. MRN Physician documentation Clinical pharmacy documentation REMARK
Progress
note
Order
sheet
Clinical audit
Remarks on the progress note
and management plan
Medication
profile
Medication
reconciliation
Pharmaceutical
progress daily
787887 PROGRESS AT LEAST DAILY NA NA NA
786540 NA NA NA
786352 NA NA NA
PREVIOUSLY ADMITTED PATIENTS AUDIT TOOL
WARD NAME……………BURN………… previously Admitted pts _____12____ Total pts
Sampling method
•Previous admissions - Total chart to be audited (N) = 15% of total patients (5 if 30 beds, 3 if 10 beds)
Sampling : Lottery method for 1st MRN from 1 to N -> every Nth (As per the order on the automation)
7. MRN Physician documentation Clinical pharmacy documentation REMARK
Progress
note
Order
sheet
Clinical audit
Remarks on the progress note
and management plan
Medication
profile
Medication
reconciliation
Pharmaceutical
progress daily
758343 NA NA NA
774716 NA NA NA
788592 ORDER REVISE DAILY NA NA NA
PREVIOUSLY ADMITTED PATIENTS AUDIT TOOL
WARD NAME……PLASTIC……………previously Admitted pts ______19____ Total pts
Sampling method
•Previous admissions - Total chart to be audited (N) = 15% of total patients (5 if 30 beds, 3 if 10 beds)
Sampling : Lottery method for 1st MRN from 1 to N -> every Nth (As per the order on the automation)
8. MRN Physician documentation Clinical pharmacy documentation REMARK
Progress
note
Order
sheet
Clinical audit
Remarks on the progress note
and management plan
Medication
profile
Medication
reconciliation
Pharmaceutical
progress daily
786959 NA NA NA
788993 PROGRESS AT LEAST DAILY NA NA NA
PREVIOUSLY ADMITTED PATIENTS AUDIT TOOL
WARD NAME…………NICU………………………previously Admitted pts ____8______ Total pts
Sampling method
•Previous admissions - Total chart to be audited (N) = 15% of total patients (5 if 30 beds, 3 if 10 beds)
Sampling : Lottery method for 1st MRN from 1 to N -> every Nth (As per the order on the automation)
9. MRN Physician documentation Clinical pharmacy documentation REMARK
Progress
note
Order
sheet
Clinical audit
Remarks on the progress note
and management plan
Medication
profile
Medication
reconciliation
Pharmaceutical
progress daily
786978 NA NA NA
788841 NA NA NA
788547 NA NA NA
PREVIOUSLY ADMITTED PATIENTS AUDIT TOOL
WARD NAME………NEONATAL……………………previously Admitted pts _____17_____ Total pts
Sampling method
•Previous admissions - Total chart to be audited (N) = 15% of total patients (5 if 30 beds, 3 if 10 beds)
Sampling : Lottery method for 1st MRN from 1 to N -> every Nth (As per the order on the automation)
10. MRN Physician documentation Clinical pharmacy documentation REMARK
Progress
note
Order
sheet
Clinical audit
Remarks on the progress note
and management plan
Medication
profile
Medication
reconciliation
Pharmaceutical
progress daily
789133 NA NA NA
726912 ORDER REVISE DAILY NA NA NA
PREVIOUSLY ADMITTED PATIENTS AUDIT TOOL
WARD NAME………PEDI SAM………………………previously Admitted pts __________ Total pts
Sampling method
•Previous admissions - Total chart to be audited (N) = 15% of total patients (5 if 30 beds, 3 if 10 beds)
Sampling : Lottery method for 1st MRN from 1 to N -> every Nth (As per the order on the automation)
