2016 Memorial Emergency Epic Documentation Audit Tool ED CSN#. Diagnosis, Was the following Yes. «| No. | NA documented? ESI completo and correct? IFnot correct why? Pain level documented? Retuired Screenings comploted? Assessment Notes Was the following documented? Yes No | NIA ED Assossmont in correct format or marked WOL? Is the assessment appropriate for chief complaint? Reassessments documented? When there is a change in patient's status? ‘When there is a change in patient's vital signs? ‘As indicated by the patient's Cconditon/treatmentiprocedure? ‘At change of shit, transfer or tupon dischargefadmit from the ED? | Vitel Signs taken according to vital sign recommendations. during stay? Vital Signs Documented within 2Ominutes of | discharge or admission Epic Audit ToolBeier Was the folowing’ documented? IV insertion? PRN med effectiveness? Medication witness for peds or high risk medication? Completed dischargeladmission condition documentation? Yes No NIA fers Overall gradi en Impression Excellent Satisfactory Minimal Compliance Below Standards Yes No NIA Geecnent eens Comments- Epic Audit Tool