Hemodialysis Audit Documentation

V 2.0

Introduction

Resident Selection

Residents Included

Residents with active orders for dialysis treatment are included in this audit.

Business Rules

Tasks:

1. Dialysis Days - Physician’s order includes Dialysis days (Q801)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active order for dialysis treatment,
         THEN there must be an order that identifies the days of the week the resident is scheduled for dialysis treatment

      2. If the order for dialysis contains the following: and means of transportation, then Yes.  Otherwise, No.

   3. Due Date:

      1. Within 24 Hours of the order date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the dialysis order is no longer active

2. Dialysis Location- Physician’s order includes location of dialysis treatment (Q816)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active order for dialysis treatment,
         AND the resident is receiving their dialysis outside the facility,
         THEN there must be an order that identifies the location of their dialysis treatment, including the address

      2. IF a resident has an active order for dialysis treatment,
         AND the resident is receiving their dialysis in house at the facility,
         THEN there must be an order that identifies the resident is receiving their dialysis treatment in house.

   3. Due Date:

      1. Within 24 Hours of the order date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the dialysis order is no longer active

3. Dialysis Transportation - Physician’s order includes means of transportation (Q817)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active order for dialysis treatment,
         AND the resident is receiving their dialysis outside the facility,
         THEN there must be an order that identifies their means of transportation to the dialysis facility

   3. Due Date:

      1. Within 24 Hours of the order date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the dialysis order is no longer active

4. Dialysis Time - Physician’s order includes the time the resident will receive their dialysis treatment (Q818)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active order for dialysis treatment,
         THEN there must be an order that identifies what time they will be receiving their dialysis treatment

   3. Due Date:

      1. Within 24 Hours of the order date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the dialysis order is no longer active

5. Site Monitoring Order - Hemodialysis site monitoring order in place (Q803)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active order for dialysis treatment,
         THEN there must be an order to monitor the dialysis site

   3. Due Date:

      1. Within 24 Hours of the order date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the dialysis order is no longer active

6. Site Monitoring TAR - Hemodialysis site monitoring documented in TAR(Q819)

   1. Location in PCC:

      1. Orders

      2. TAR

   2. Business Rule:

      1. IF a resident has an active order for dialysis treatment,
         AND there is an order to monitor the dialysis site,
         THEN there must be a record of the site monitoring in the TAR

   3. Due Date:

      1. The Scheduled date of administration

   4. Is classified as missed on the report:

      1. After the Scheduled date has passed

   5. Is no longer relevant to the report:

      1. If the dialysis order is no longer active

7. Care Plan Vital Signs - The resident’s care plan includes monitoring vital signs (Q806)

   1. Location in PCC:

      1. Care Plan → Intervention

   2. Business Rule:

      1. IF a resident has an active order for dialysis treatment,
         THEN there must be an intervention in the care plan that addresses regular monitoring of the resident’s vital signs

   3. Due Date:

      1. Within 24 hours of the dialysis order

      2. Within 3 weeks of admission for new residents

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the dialysis order is no longer active

8. Care Plan Weight Monitoring - The resident’s care plan includes monitoring weights (Q821)

   1. Location in PCC:

      1. Care Plan → Intervention

   2. Business Rule:

      1. IF a resident has an active order for dialysis treatment,
         THEN there must be an intervention in the care plan that addresses regular weight monitoring of the resident

   3. Due Date:

      1. Within 24 hours of the dialysis order

      2. Within 3 weeks of admission for new residents

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the dialysis order is no longer active

9. Care Plan Nutrition - The resident’s care plan includes monitoring nutritional and fluid needs (Q822)

   1. Location in PCC:

      1. Care Plan → Intervention

   2. Business Rule:

      1. IF a resident has an active order for dialysis treatment,
         THEN there must be an intervention in the care plan that addresses regular monitoring of the resident’s nutritional and fluid needs

   3. Due Date:

      1. Within 24 hours of the dialysis order

      2. Within 3 weeks of admission for new residents

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the dialysis order is no longer active

10. Care Plan Dialysis Type - The resident’s care plan includes the type of dialysis services (Q807)

    1. Location in PCC:

       1. Care Plan → Intervention

    2. Business Rule:

       1. IF a resident has an active order for dialysis treatment,
          THEN there must be an intervention in the care plan that addresses what type of dialysis treatment the resident is receiving

    3. Due Date:

       1. Within 24 hours of the dialysis order

       2. Within 3 weeks of admission for new residents

    4. Is classified as missed on the report:

       1. N/A

    5. Is no longer relevant to the report:

       1. If the dialysis order is no longer active

11. Care Plan Location - The resident’s care plan includes the location of dialysis services. (Q823)

    1. Location in PCC:

       1. Care Plan → Intervention

    2. Business Rule:

       1. IF a resident has an active order for dialysis treatment,
          AND the resident receives dialysis treatment outside the facility,
          THEN there must be an intervention in the care plan that specifies the location of the dialysis treatment center

    3. Due Date:

       1. Within 24 hours of the dialysis order

       2. Within 3 weeks of admission for new residents

    4. Is classified as missed on the report:

       1. N/A

    5. Is no longer relevant to the report:

       1. If the dialysis order is no longer active

12. Care Plan Transportation - The resident’s care plan includes transportation arrangements. (Q824)

    1. Location in PCC:

       1. Care Plan → Intervention

    2. Business Rule:

       1. IF a resident has an active order for dialysis treatment,
          AND the resident receives dialysis treatment outside the facility,
          THEN there must be an intervention in the care plan that specifies the transportation arrangements for the resident

    3. Due Date:

       1. Within 24 hours of the dialysis order

       2. Within 3 weeks of admission for new residents

    4. Is classified as missed on the report:

       1. N/A

    5. Is no longer relevant to the report:

       1. If the dialysis order is no longer active

13. Care Plan Blood Pressure - The resident’s care plan indicates which arm to use for blood pressure monitoring (Q808)

    1. Location in PCC:

       1. Care Plan → Intervention

    2. Business Rule:

       1. IF a resident has an active order for dialysis treatment,
          THEN there must be an intervention in the care plan that specifies which arm to use for blood pressure monitoring

    3. Due Date:

       1. Within 24 hours of the dialysis order

       2. Within 3 weeks of admission for new residents

    4. Is classified as missed on the report:

       1. N/A

    5. Is no longer relevant to the report:

       1. If the dialysis order is no longer active

14. Care Plan Emergency Contact - The care plan includes the contact information of the dialysis center for dialysis-related emergencies, concerns, or complications (Q809)

    1. Location in PCC:

       1. Care Plan → Intervention

    2. Business Rule:

       1. IF a resident has an active order for dialysis treatment,
          AND the resident receives dialysis treatment outside the facility,
          THEN there must be an intervention in the care plan that includes the phone number of the dialysis facility

    3. Due Date:

       1. Within 24 hours of the dialysis order

       2. Within 3 weeks of admission for new residents

    4. Is classified as missed on the report:

       1. N/A

    5. Is no longer relevant to the report:

       1. If the dialysis order is no longer active

15. Care Plan Risk Factors - The resident’s care plan includes monitoring for risk factors and managing complications such as hemorrhage, access site information, etc. (Q810, Q825)

    1. Location in PCC:

       1. Care Plan → Intervention

    2. Business Rule:

       1. IF a resident has an active order for dialysis treatment,
          THEN there must be an intervention in the care plan that addresses regular monitoring of the dialysis access site for risk factors, including:

          1. Hemorrhaging

          2. Infection

    3. Due Date:

       1. Within 24 hours of the dialysis order

       2. Within 3 weeks of admission for new residents

    4. Is classified as missed on the report:

       1. N/A

    5. Is no longer relevant to the report:

       1. If the dialysis order is no longer active

16. Care Plan Access Site Care - The resident’s care plan includes assessment and care of access site, including use of PPE as necessary (Q811)

    1. Location in PCC:

       1. Care Plan → Intervention

    2. Business Rule:

       1. IF a resident has an active order for dialysis treatment,
          THEN there must be an intervention in the care plan that addresses the care of the dialysis access site including:

          1. Assessment of site

          2. Site care

          3. Use of PPE

    3. Due Date:

       1. Within 24 hours of the dialysis order

       2. Within 3 weeks of admission for new residents

    4. Is classified as missed on the report:

       1. N/A

    5. Is no longer relevant to the report:

       1. If the dialysis order is no longer active

17. Care Plan Medication Administration - The resident’s care plan includes approach to administering medications (Q812)

    1. Location in PCC:

       1. Care Plan → Intervention

    2. Business Rule:

       1. IF a resident has an active order for dialysis treatment,
          THEN there must be an intervention in the care plan that addresses administering medications before, during, and after dialysis according to MD orders

    3. Due Date:

       1. Within 24 hours of the dialysis order

       2. Within 3 weeks of admission for new residents

    4. Is classified as missed on the report:

       1. N/A

    5. Is no longer relevant to the report:

       1. If the dialysis order is no longer active