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Table 3 Key items included within the Chart audit/ observational toolac

From: CogChamps: impact of a project to educate nurses about delirium and improve the quality of care for hospitalized patients with cognitive impairment

Chart/ Room audit items Response
Cognition
Was the patient’s cognitive functioning assessed using a standardized assessment tool (e.g. MSQ, MMSE) within 24 h of the patient’s admission to the ward? Yes/ No
Was the patient’s cognitive functioning assessed informally (i.e. not using a standardised assessment tool). Comments may include ‘oriented to person, time, place’ or ‘memory OK etc.’ Yes/ No
Pain Assessment and Management
Was a pain assessment undertaken within the last 24 h/ since the last observation? Yes/ No
Was analgesia administered within the last 24 h/ since the last observation? Yes/ No
Medication Use
Was antipsychotic medication administered to the patient within the last 24 h/ since the last observation? Yes/ No
Was benzodiazepine medication administered to the patient within the last 24 h/ since the last observation? Yes/ No
Items requiring direct observation Response
Behavior
Did the patient display symptoms of agitation (e.g. moaning, calling out, pacing, fidgeting, hand wringing etc.) OR pain OR discomfort (e.g. frowning, grimacing, holding onto any part of his/ her body, crying or moaning etc.)? Yes/ No/ N/Ab
What was the patient doing at the time of the observation? Various, e.g. Asleep/ Lying in bed – no activity – engaged in activity / Sitting in chair
Orientation
Did the nurse address the patient by name when he/ she interacted with the patient? Yes/ No / N/A
Did the nurse introduce themselves when they interacted with the patient? Yes/ No/ N/A
Did the nurse re-orient the patient if confusion/dis-orientation was evident? Yes/ No / N/A
Communication
Did the nurse explain the activity/ procedure in easy-to-understand terms to the patient? Yes/ No / N/A
Nutrition
Was adequate assistance provided to the patient if the patient had difficulty eating or drinking during meal-times?
Yes/ No / N/A
  1. aExamples of each category are included for illustrative purposes
  2. bN/A – Not Applicable - either the patient or nurse was not present during the observation period
  3. cA number of additional items were included in the audit tool (e.g. Did the patient had an indwelling catheter in situ? Had a restraint order been written for the patient?), however the incidence was very low (there were nil restraint orders) and have not been included in this report as they were considered uninformative