Intravenous Audit Documentation

V 2.0

Introduction

Resident Selection

Residents Included

Any resident with an order for an IV, whether for the purpose of hydration, nutrition, or medication is included in this Audit.

Business Rules

Tasks:

1. IV Administrated MAR - IV Medication, Hydration, or Nutrition is documented in the MAR without charting omission. (Q2102)

   1. Location in PCC:

      1. Orders

      2. MAR

   2. Business Rule:

      1. IF a resident has an order for hydration, nutrition, OR medication to be administered intravenously,
         THEN the administration must be filled out correctly in the MAR

   3. Due Date:

      1. The scheduled time of administration

   4. Is classified as missed on the report:

      1. The next scheduled time of administration

   5. Is no longer relevant to the report:

      1. If the order is no longer active

2. Prior Medication IV Flush Order - Order for flush prior to medication infusion in place (Q2103, Q2121)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an order for medication to be administered intravenously,
         THEN there must be an order for prior infusion flushing,
         AND the order must have a regular schedule in place.

   3. Due Date:

      1. The scheduled time of administration

   4. Is classified as missed on the report:

      1. The next scheduled time of administration

   5. Is no longer relevant to the report:

      1. If the order is no longer active

3. Medication IV Flush TAR - order for flush prior to medication infusion administered without omission (Q2109)

   1. Location in PCC:

      1. Orders

      2. TAR

   2. Business Rule:

      1. IF a resident has an order for medication to be administered intravenously,
         AND there is an order for prior infusion flushing,
         THEN the administration must be filled out correctly in the TAR 

   3. Due Date:

      1. The scheduled time of administration

   4. Is classified as missed on the report:

      1. The next scheduled time of administration

   5. Is no longer relevant to the report:

      1. If the order is no longer active

4. Post Medication IV Flush Order - Order for flush post medication infusion in place (Q2122, Q2123)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an order for medication to be administered intravenously,
         THEN there must be an order for post infusion flushing,
         AND the order must have a regular schedule in place.

   3. Due Date:

      1. The scheduled time of administration

   4. Is classified as missed on the report:

      1. The next scheduled time of administration

   5. Is no longer relevant to the report:

      1. If the order is no longer active

5. Medication IV Flush TAR - order for flush post medication infusion administered without omission (Q2124)

   1. Location in PCC:

      1. Orders

      2. TAR

   2. Business Rule:

      1. IF a resident has an order for medication to be administered intravenously,
         AND there is an order for post infusion flushing,
         THEN the administration must be filled out correctly in the TAR 

   3. Due Date:

      1. The scheduled time of administration

   4. Is classified as missed on the report:

      1. The next scheduled time of administration

   5. Is no longer relevant to the report:

      1. If the order is no longer active

6. Catheter Site Dressing Change Order - Order for catheter site dressing in place. (Q2104, Q2116) 

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an order indicating that the resident has any of the following intravenous lines:

         1.  PICC Line

         2. Mid-Line

         3. Central Line

         4. Peripheral Line

THEN there must be an order for catheter site dressing change,
AND the order must have a regular schedule in place.

3. Due Date:

   1. Within 24 Hours of the order

4. Is classified as missed on the report:

   1. N/A

5. Is no longer relevant to the report:

   1. If the PICC Line order is no longer active

7. Catheter Site Dressing Change TAR- Order for catheter site dressing is administered without omission in the TAR (Q2111)

   1. Location in PCC:

      1. Orders

      2. TAR

   2. Business Rule:

      1. IF a resident has an order indicating that the resident has any of the following intravenous lines:

         1.  PICC Line

         2. Mid-Line

         3. Central Line

         4. Peripheral Line

AND they have an order for catheter site dressing change,
THEN  the administration must be filled out correctly in the TAR 

3. Due Date:

   1. The scheduled time of administration

4. Is classified as missed on the report:

   1. The next scheduled time of administration

5. Is no longer relevant to the report:

   1. If the order is no longer active

8. Measure External Catheter Length Order - order to measure external catheter length with each dressing change in place (Q2105, Q2117)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an order indicating that the resident has a PICC Line
         THEN there must be an order for to measure the external catheter length,
         AND the order must have a regular schedule in place.

   3. Due Date:

      1. Within 24 Hours of the order

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the PICC Line order is no longer active

9. Measure External Catheter Length MAR - Order for external catheter measurement is administered without omission in the TAR (Q2112)

   1. Location in PCC:

      1. Orders

      2. TAR

   2. Business Rule:

      1. IF a resident has an order indicating that the resident has a PICC Line,
         AND they have an order to measure the external catheter length,
         THEN  the administration must be filled out correctly in the TAR 

   3. Due Date:

      1. The scheduled time of administration

   4. Is classified as missed on the report:

      1. The next scheduled time of administration

   5. Is no longer relevant to the report:

      1. If the order is no longer active

10. Change Needleless Connector Order - order to change needleless connector with site change in place (Q2106, Q2118)

    1. Location in PCC:

       1. Orders

    2. Business Rule:

       1. IF a resident has an order indicating that the resident has any of the following intravenous lines:

          1.  PICC Line

          2. Mid-Line

          3. Central Line

          4. Peripheral Line

THEN there must be an order for to change the needleless connector with site change,
AND the order must have a regular schedule in place.

3. Due Date:

   1. Within 24 Hours of the order

4. Is classified as missed on the report:

   1. N/A

5. Is no longer relevant to the report:

   1. If the PICC Line order is no longer active

11. Change Needleless Connector MAR - Order to change needleless connector is administered without omission in the TAR (Q2113)

    1. Location in PCC:

       1. Orders

       2. TAR

    2. Business Rule:

       1. IF a resident has an order indicating that the resident has any of the following intravenous lines:

          1.  PICC Line

          2. Mid-Line

          3. Central Line

          4. Peripheral Line

AND they have an order to change the needleless connector with site change,
THEN  the administration must be filled out correctly in the TAR 

3. Due Date:

   1. The scheduled time of administration

4. Is classified as missed on the report:

   1. The next scheduled time of administration

5. Is no longer relevant to the report:

   1. If the order is no longer active

12. Observation of Site Order - order to observe IV site every shift in place (Q2107, Q2119)

    1. Location in PCC:

       1. Orders

    2. Business Rule:

       1. IF a resident has an order indicating that the resident has any of the following intravenous lines:

          1.  PICC Line

          2. Mid-Line

          3. Central Line

          4. Peripheral Line

THEN there must be an order for to observe the site,
AND the order must have a regular schedule in place.

3. Due Date:

   1. Within 24 Hours of the order

4. Is classified as missed on the report:

   1. N/A

5. Is no longer relevant to the report:

   1. If the IV Line order is no longer active

13. Observation of Site MAR - Order to observe IV site is administered without omission in the TAR (Q2114)

    1. Location in PCC:

       1. Orders

       2. TAR

    2. Business Rule:

       1. IF a resident has an order indicating that the resident has any of the following intravenous lines:

          1.  PICC Line

          2. Mid-Line

          3. Central Line

          4. Peripheral Line

AND they have an order to observe the IV site,
THEN  the administration must be filled out correctly in the TAR 

3. Due Date:

   1. The scheduled time of administration

4. Is classified as missed on the report:

   1. The next scheduled time of administration

5. Is no longer relevant to the report:

   1. If the order is no longer active

14. Change Administration Set Order - order to change administration set every 24 hours in place (Q2108, Q2120) 

    1. Location in PCC:

       1. Orders

    2. Business Rule:

       1. IF a resident has an order indicating that the resident has any of the following intravenous lines:

          1.  PICC Line

          2. Mid-Line

          3. Central Line

          4. Peripheral Line

       2. THEN there must be an order for to change the administration set,
          AND the order must include a schedule of every 24 hours.

    3. Due Date:

       1. Within 24 Hours of the order

    4. Is classified as missed on the report:

       1. N/A

    5. Is no longer relevant to the report:

       1. If the IV Line order is no longer active

15. Change Administration Set MAR - Order to change administration set is administered without omission in the TAR (Q2115)

    1. Location in PCC:

       1. Orders

       2. TAR

    2. Business Rule:

       1. IF a resident has an order indicating that the resident has any of the following intravenous lines:

          1.  PICC Line

          2. Mid-Line

          3. Central Line

          4. Peripheral Line

AND they have an order to change the administration set,
THEN  the administration must be filled out correctly in the TAR 

3. Due Date:

   1. The scheduled time of administration

4. Is classified as missed on the report:

   1. The next scheduled time of administration

5. Is no longer relevant to the report:

   1. If the order is no longer active

16. Care Plan - Intravenous Care Plan in place and updated (Q2110)

    1. Location in PCC:

       1. Care plan

          1. Focus

    2. Business Rule:

       1. IF a resident has an order indicating any type of IV Line
          THEN there must be a care plan indicating Intravenous treatment

    3. Due Date:

       1. Within 24 Hours of the IV order
          OR 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 IV Line order is no longer active