Tracheostomy Audit Documentation

V 2.0

Introduction

Resident Selection

Residents Included

All residents with active orders for a tracheostomy (found in the “Orders“ tab on PCC’s front end).

Business Rules

Tasks:

1. Tube Size - Physician Must Fill Out Order Properly for Trach, Including Size. (Q1802)

   1. Location in PCC:

      1. Orders

   2. Business Rule

      1. IF a resident has an active physician order for a trach tube,
         THEN the physician’s order must include the size of the tube.

   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 If the tracheostomy order is no longer active.

2. Trach Type - Physician Must Fill Out Order Properly for Trach, Including Type. (Q1811)

   1. Location in PCC:

      1. Orders

   2. Business Rule

      1. IF a resident has an active physician order for a trach tube,
         THEN there must be a physician’s order that includes the type of tube.

   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 If the tracheostomy order is no longer active.

3. Trach Care -  Physician Must Fill Out Order Properly for Trach Care, Including a Proper Schedule. (Q1812)

   1. Location in PCC:

      1. Orders

   2. Business Rule

      1. IF a resident has an active physician order for a trach tube,
         AND the resident has an active physician order for trach care,
         THEN the physician’s order must include: 

         1. A schedule to perform trach care every shift,

         2. Instructions to perform trach care PRN.

   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 If the tracheostomy order is no longer active.

4. Trach Tie Maintenance - Physician Must Fill Out Order Properly for Changing Trach Ties, Including a Proper Schedule. (Q1803)

   1. Location in PCC:

      1. Orders

   2. Business Rule

      1. IF a resident has an active physician order for a trach tube,
         AND the resident has an active physician order for changing the trach ties,
         THEN the physician’s order must include: 

         1. A schedule to change the trach ties at least 2 times per week,

         2. Instructions to change the ties PRN.

   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 tracheostomy order is no longer active.

5. Trach Mask Maintenance - Physician Must Fill Out Order Properly for Changing Trach Mask, Including a Proper Schedule and Proper Recording Instructions. (Q1804)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active physician order for a trach tube,
         AND the order indicates the resident has a trach mask/collar,
         AND the resident has an active physician order for changing the trach mask or collar,
         THEN  the physician’s order must include instructions to write initials and the date on the changed tubing, 
         AND the physician’s order must include:

         1. A schedule to change the trach mask/collar at least once per week,

         2. Instructions to change the mask PRN.

   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 tracheostomy order is no longer active.

6. Suction Equipment Maintenance - Physician Must Fill Out Order Properly for Changing Suction Equipment, Including a Proper Schedule. (Q1805)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active physician order for a trach tube,
         AND the resident has an active physician order for changing the suction equipment,
         THEN the physician’s order must include:

         1. A schedule to change the suction equipment at least once per week,

         2. Instructions to change the suction equipment PRN.

   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 tracheostomy order is no longer active

7. Trach Suctioning - Physician Must Fill Out Order Properly for Routine Trach Suctioning, Including a Proper Schedule. (Q1806, Q1820)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active physician order for a trach tube,
         THEN the resident requires an active physician order for suctioning secretions around the trach site,
         AND the physician’s order must include: a schedule to suction secretions every shift

   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 tracheostomy order is no longer active

8. Trach Care TAR - Physician’s order for Trach Care is being Administered in the TAR (Q1808)

   1. Location in PCC:

      1. Orders 

         1. Administration Record

   2. Business Rule:

      1. IF a resident has an active physician order for a trach tube,
         AND the resident has an active physician order for trach care 
         THEN the Administration of that order must be recorded 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 tracheostomy order is no longer active

9. Trach Suctioning TAR - Physician’s order for Trach Suctioning is being Administered in the TAR (Q1813)

   1. Location in PCC:

      1. Orders 

         1. Administration Record

   2. Business Rule:

      1. IF a resident has an active physician order for a trach tube,
         AND the resident has an active physician order for trach suctioning
         THEN the Administration of that order must be recorded 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 tracheostomy order is no longer active

10. Care Plan - Resident’s Tracheostomy Care plan in place (Q1810)

    1. Location in PCC:

       1. Care Plan

          1. Focus

    2. Business Rule:

       1. IF a resident has an active physician order for a trach tube,
          THEN the resident requires a Care Plan Focus addressing their Tracheostomy.

    3. Due Date:

       1. Within 24 Hours of the order date OR

       2. 3 weeks after 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 tracheostomy order is no longer active