Sync template from atomicqms-style deployment
This commit is contained in:
66
Forms/FRM-001-Document-Change-Request.md
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66
Forms/FRM-001-Document-Change-Request.md
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# Document Change Request Form
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| Form ID | FRM-001 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Section 1: Request Information
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| Field | Entry |
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|-------|-------|
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| Request Date | |
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| Requested By | |
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| Department | |
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## Section 2: Document Information
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| Field | Entry |
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|-------|-------|
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| Document Number | |
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| Document Title | |
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| Current Revision | |
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## Section 3: Change Description
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### Type of Change
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- [ ] New Document
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- [ ] Revision to Existing Document
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- [ ] Document Obsolescence
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### Description of Change
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*(Describe the proposed change in detail)*
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### Reason for Change
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*(Explain why this change is needed - e.g., regulatory update, safety concern, process improvement)*
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## Section 4: Impact Assessment
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### Affected Areas
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- [ ] Training Required
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- [ ] Other Documents Affected
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- [ ] Process Changes Required
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- [ ] Equipment or Supply Changes
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- [ ] Patient Safety Impact
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### List Affected Documents
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## Section 5: Approvals
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| Role | Name | Signature | Date |
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|------|------|-----------|------|
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| Requester | | | |
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| Document Owner | | | |
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| Quality Assurance | | | |
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---
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*Form FRM-001 Rev 1.0*
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110
Forms/FRM-003-CAPA-Form.md
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110
Forms/FRM-003-CAPA-Form.md
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# Corrective and Preventive Action (CAPA) Form
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| Form ID | FRM-003 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Section 1: CAPA Identification
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| Field | Entry |
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|-------|-------|
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| CAPA Number | |
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| Date Initiated | |
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| Initiated By | |
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| CAPA Owner | |
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| Target Closure Date | |
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## Section 2: Classification
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### Type
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- [ ] Corrective Action
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- [ ] Preventive Action
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### Source
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- [ ] Patient Safety Event
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- [ ] Medication Error
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- [ ] Healthcare-Associated Infection
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- [ ] Equipment Failure
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- [ ] Internal Audit
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- [ ] External Audit/Survey
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- [ ] Family Complaint
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- [ ] Process Deviation
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- [ ] Sentinel Event
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- [ ] Management Review
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- [ ] Other: ____________
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### Priority
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- [ ] Critical (patient harm occurred or high risk - 5 business days)
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- [ ] Major (potential for patient harm - 15 business days)
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- [ ] Minor (process deviation, no patient impact - 30 business days)
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## Section 3: Problem Description
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*(Describe the nonconformity or potential nonconformity - include patient impact if applicable)*
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## Section 4: Immediate Containment
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*(Actions taken to contain the immediate impact and protect patient safety)*
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## Section 5: Root Cause Investigation
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### Investigation Method Used
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- [ ] Root Cause Analysis (RCA)
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- [ ] Failure Mode and Effects Analysis (FMEA)
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- [ ] 5 Whys
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- [ ] Fishbone Diagram
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- [ ] Fault Tree Analysis
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- [ ] Other: ____________
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### Root Cause Determination
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### Contributing Factors
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## Section 6: Corrective/Preventive Actions
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| Action | Responsible | Due Date | Status |
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|--------|-------------|----------|--------|
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| | | | |
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| | | | |
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| | | | |
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## Section 7: Staff Communication and Training
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| Training/Communication Required | Target Audience | Completion Date |
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|--------------------------------|-----------------|-----------------|
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| | | |
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## Section 8: Effectiveness Verification
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| Criteria | Method | Result |
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|----------|--------|--------|
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| | | |
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Verification Date: ____________
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Verified By: ____________
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## Section 9: Closure
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| Role | Name | Signature | Date |
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|------|------|-----------|------|
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| CAPA Owner | | | |
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| Quality Approval | | | |
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### Lessons Learned
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---
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*Form FRM-003 Rev 1.0*
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87
Forms/FRM-004-Training-Record.md
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87
Forms/FRM-004-Training-Record.md
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# Training Record Form
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| Form ID | FRM-004 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Section 1: Employee Information
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| Field | Entry |
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|-------|-------|
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| Employee Name | |
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| Employee ID | |
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| Department | |
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| Job Title | |
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## Section 2: Training Information
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| Field | Entry |
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|-------|-------|
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| Training Title | |
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| Training Date | |
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| Training Duration | |
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| Trainer Name | |
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| Trainer Qualification | |
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### Training Type
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- [ ] Initial Training
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- [ ] Retraining
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- [ ] Annual Competency
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- [ ] Procedure Update
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- [ ] Equipment Training
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- [ ] Certification (NRP, PALS, etc.)
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### Delivery Method
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- [ ] Classroom
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- [ ] On-the-Job
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- [ ] Simulation
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- [ ] Self-Study
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- [ ] Computer-Based
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- [ ] Other: ____________
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## Section 3: Training Content
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*(List topics covered or attach training materials)*
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## Section 4: Assessment
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### Assessment Method
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- [ ] Written Test
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- [ ] Practical Demonstration
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- [ ] Verbal Assessment
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- [ ] Return Demonstration
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- [ ] Observation of Clinical Practice
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- [ ] Simulation Performance
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### Assessment Results
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| Metric | Result |
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|--------|--------|
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| Score (if applicable) | |
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| Pass/Fail | |
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### Competency Validated
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- [ ] Yes - Employee demonstrates competency
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- [ ] No - Retraining required
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## Section 5: Signatures
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| Role | Name | Signature | Date |
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|------|------|-----------|------|
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| Trainee | | | |
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| Trainer | | | |
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| Supervisor | | | |
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## Section 6: Follow-up (if retraining required)
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| Date | Action Taken | Result |
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|------|--------------|--------|
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| | | |
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---
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*Form FRM-004 Rev 1.0*
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71
Forms/FRM-006-Audit-Checklist.md
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71
Forms/FRM-006-Audit-Checklist.md
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# Internal Audit Checklist
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| Form ID | FRM-006 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Section 1: Audit Information
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| Field | Entry |
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|-------|-------|
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| Audit Date | |
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| Auditor Name | |
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| Area/Process Audited | |
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| Audit Type | [ ] Process [ ] Document [ ] Compliance [ ] Mock Survey |
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## Section 2: Audit Scope
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**Standards/Requirements:**
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**Documents Reviewed:**
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**Personnel Interviewed:**
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## Section 3: Audit Checklist
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| Item # | Requirement | Compliant | Finding | Evidence |
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|--------|-------------|-----------|---------|----------|
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| 1 | | [ ] Y [ ] N [ ] NA | | |
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| 2 | | [ ] Y [ ] N [ ] NA | | |
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| 3 | | [ ] Y [ ] N [ ] NA | | |
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| 4 | | [ ] Y [ ] N [ ] NA | | |
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| 5 | | [ ] Y [ ] N [ ] NA | | |
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| 6 | | [ ] Y [ ] N [ ] NA | | |
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| 7 | | [ ] Y [ ] N [ ] NA | | |
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| 8 | | [ ] Y [ ] N [ ] NA | | |
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| 9 | | [ ] Y [ ] N [ ] NA | | |
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| 10 | | [ ] Y [ ] N [ ] NA | | |
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## Section 4: Findings Summary
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### Critical Findings (Immediate patient safety risk)
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### Major Findings (Significant non-compliance)
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### Minor Findings (Documentation or procedural deviation)
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### Observations (Opportunities for improvement)
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## Section 5: Positive Observations
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## Section 6: Signatures
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| Role | Name | Signature | Date |
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|------|------|-----------|------|
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| Auditor | | | |
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| Auditee | | | |
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---
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*Form FRM-006 Rev 1.0*
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0
Forms/Nutrition/.gitkeep
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0
Forms/Nutrition/.gitkeep
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143
Forms/Nutrition/FRM-NUT-001-TPN-Order-Form.md
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143
Forms/Nutrition/FRM-NUT-001-TPN-Order-Form.md
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# Total Parenteral Nutrition (TPN) Order Form
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| Form ID | FRM-NUT-001 | Revision | 1.0 |
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|---------|-------------|----------|-----|
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---
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## Patient Information
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| Field | Entry |
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|-------|-------|
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| Patient Name | |
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| MRN | |
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| Date of Birth | |
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| Weight | ______ kg (Date: ______) |
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| Gestational Age (if neonate) | ______ weeks |
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| Order Date | |
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| Start Date/Time | |
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## TPN Type
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- [ ] Central TPN (peripherally unsafe)
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- [ ] Peripheral TPN
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- [ ] Transitional (enteral feeds advancing)
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## Base Solution
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### Dextrose
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- Concentration: ______ % (peripherally safe ≤ 12.5%)
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- Goal calories from dextrose: ______ kcal/kg/day
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### Amino Acids
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- [ ] TrophAmine (pediatric)
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- [ ] Aminosyn
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- Concentration: ______ g/dL
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- Goal protein: ______ g/kg/day
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|
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### Lipids
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- [ ] Intralipid 20%
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- [ ] SMOFlipid 20%
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- Dose: ______ g/kg/day
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- [ ] Infuse over 24 hours
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- [ ] Infuse over ______ hours
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## Electrolytes (per liter or per day)
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| Electrolyte | Amount | Unit |
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|-------------|--------|------|
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| Sodium Chloride | | mEq/L or mEq/day |
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| Sodium Acetate | | mEq/L or mEq/day |
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| Potassium Chloride | | mEq/L or mEq/day |
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| Potassium Acetate | | mEq/L or mEq/day |
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| Potassium Phosphate | | mmol/L or mmol/day |
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| Calcium Gluconate | | mEq/L or mEq/day |
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| Magnesium Sulfate | | mEq/L or mEq/day |
|
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## Vitamins and Trace Elements
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- [ ] MVI Pediatric: ______ mL/day
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- [ ] MVI-12 (>11 years): ______ mL/day
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- [ ] Trace Elements Pediatric: ______ mL/day
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- [ ] Zinc (additional): ______ mcg/kg/day
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- [ ] Selenium (additional): ______ mcg/kg/day
|
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|
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## Volume and Rate
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**Total Volume:** ______ mL/day
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|
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**Infusion Rate:** ______ mL/hour
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|
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**Goal Fluid Intake:** ______ mL/kg/day
|
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|
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## Additional Additives
|
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|
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| Medication | Dose | Indication |
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|------------|------|------------|
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| Heparin | | mL |
|
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| Carnitine | | mg |
|
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| Cysteine | | mg |
|
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| Vitamin K | | mg |
|
||||
| Other: | | |
|
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|
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## Enteral Nutrition
|
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|
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**Current Enteral Intake:** ______ mL/kg/day
|
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|
||||
**Enteral Formula/Breast Milk:**
|
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- Type: ______
|
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- Rate: ______ mL/hour or ______ mL q____hours
|
||||
|
||||
**Plan:**
|
||||
- [ ] NPO
|
||||
- [ ] Advancing enteral feeds
|
||||
- [ ] Stable enteral feeds
|
||||
|
||||
## Laboratory Monitoring
|
||||
|
||||
### Required Labs
|
||||
- [ ] Daily: BMP, ionized calcium, magnesium, phosphorus
|
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- [ ] Twice weekly: CBC, LFTs, triglycerides, albumin
|
||||
- [ ] Weekly: Zinc, selenium (if on long-term TPN)
|
||||
|
||||
### Latest Laboratory Values
|
||||
|
||||
| Lab | Value | Date |
|
||||
|-----|-------|------|
|
||||
| Glucose | | |
|
||||
| Sodium | | |
|
||||
| Potassium | | |
|
||||
| Chloride | | |
|
||||
| CO2 | | |
|
||||
| BUN | | |
|
||||
| Creatinine | | |
|
||||
| Calcium (ionized) | | |
|
||||
| Phosphorus | | |
|
||||
| Magnesium | | |
|
||||
| Triglycerides | | |
|
||||
| AST/ALT | | |
|
||||
| Bilirubin (total/direct) | | |
|
||||
|
||||
## Special Instructions
|
||||
|
||||
|
||||
|
||||
## Pharmacist Review
|
||||
|
||||
**Reviewed by:** ______________________ **Date/Time:** ______________
|
||||
|
||||
**Comments/Recommendations:**
|
||||
|
||||
|
||||
|
||||
## Physician Order
|
||||
|
||||
**Ordered by:** ______________________ **Date/Time:** ______________
|
||||
|
||||
**Attending Physician Verification:** ______________________ **Date/Time:** ______________
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-NUT-001 Rev 1.0*
|
||||
|
||||
**CRITICAL:** Verify calculations before compounding. Check for incompatibilities. Ensure peripheral safety if no central access.
|
||||
0
Forms/Patient-Safety/.gitkeep
Normal file
0
Forms/Patient-Safety/.gitkeep
Normal file
138
Forms/Patient-Safety/FRM-SAF-001-Daily-Safety-Checklist.md
Normal file
138
Forms/Patient-Safety/FRM-SAF-001-Daily-Safety-Checklist.md
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@@ -0,0 +1,138 @@
|
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# NICU/PICU Daily Safety Checklist
|
||||
|
||||
| Form ID | FRM-SAF-001 | Revision | 1.0 |
|
||||
|---------|-------------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Patient Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Patient Name | |
|
||||
| MRN | |
|
||||
| Location | |
|
||||
| Date | |
|
||||
| Shift | [ ] Day [ ] Night |
|
||||
|
||||
## Patient Identification and Communication
|
||||
|
||||
- [ ] Patient armband in place and accurate
|
||||
- [ ] Allergies documented and displayed
|
||||
- [ ] Code status clearly posted
|
||||
- [ ] Isolation precautions posted (if applicable)
|
||||
- [ ] Bedside safety brief completed with team
|
||||
|
||||
## Airway and Respiratory
|
||||
|
||||
- [ ] ETT secured and position marked/documented
|
||||
- [ ] ETT depth verified and matches previous
|
||||
- [ ] Ventilator settings match orders
|
||||
- [ ] Oxygen delivery device appropriate
|
||||
- [ ] Suction equipment at bedside and functioning
|
||||
- [ ] Ambu bag with appropriate mask at bedside
|
||||
- [ ] Inline suction system functioning (if applicable)
|
||||
|
||||
## Vascular Access
|
||||
|
||||
- [ ] All IV sites assessed for infiltration/infection
|
||||
- [ ] Central line dressing clean, dry, intact (date: ______)
|
||||
- [ ] PICC line secured, dressing intact
|
||||
- [ ] Umbilical lines secured (if applicable)
|
||||
- [ ] All IV infusions verified against MAR
|
||||
- [ ] IV pump alarms functional
|
||||
- [ ] Flushing protocol followed per policy
|
||||
|
||||
## Medications
|
||||
|
||||
- [ ] High-alert medications double-checked
|
||||
- [ ] Infusion pump rates verified
|
||||
- [ ] Vasopressor/inotrope concentrations verified
|
||||
- [ ] Sedation/analgesia infusions verified
|
||||
- [ ] Insulin infusion verified (if applicable)
|
||||
- [ ] Heparin infusion verified (if applicable)
|
||||
- [ ] Smart pump drug library enabled
|
||||
|
||||
## Monitoring and Alarms
|
||||
|
||||
- [ ] Cardiac monitor leads in place
|
||||
- [ ] Monitor alarm limits set appropriately
|
||||
- [ ] SpO2 probe positioned correctly
|
||||
- [ ] Blood pressure cuff size appropriate
|
||||
- [ ] Temperature monitoring functioning
|
||||
- [ ] All alarms audible and enabled
|
||||
|
||||
## Feeding and Nutrition
|
||||
|
||||
- [ ] Feeding tube position verified before use
|
||||
- [ ] Enteral feeding pump rate matches order
|
||||
- [ ] Breast milk/formula labeled correctly
|
||||
- [ ] Feeding advancement per protocol
|
||||
- [ ] Aspiration precautions in place
|
||||
- [ ] Head of bed elevated (if not contraindicated)
|
||||
|
||||
## Infection Prevention
|
||||
|
||||
- [ ] Hand hygiene performed
|
||||
- [ ] Central line bundle elements met (if applicable)
|
||||
- [ ] Hand hygiene
|
||||
- [ ] Chlorhexidine bath (if >2 months)
|
||||
- [ ] Line necessity assessed
|
||||
- [ ] Dressing intact
|
||||
- [ ] VAE prevention bundle (if ventilated)
|
||||
- [ ] HOB elevated 30 degrees (unless contraindicated)
|
||||
- [ ] Oral care performed
|
||||
- [ ] Sedation vacation/assessment
|
||||
- [ ] Contact isolation for MDRO (if applicable)
|
||||
|
||||
## Skin Integrity
|
||||
|
||||
- [ ] Skin assessment completed
|
||||
- [ ] Pressure areas assessed and repositioned
|
||||
- [ ] Medical device-related pressure injury prevention
|
||||
- [ ] Diaper area assessed
|
||||
- [ ] Ostomy sites intact (if applicable)
|
||||
|
||||
## Safety Equipment
|
||||
|
||||
- [ ] Bed in lowest position when not at bedside
|
||||
- [ ] Side rails up appropriately
|
||||
- [ ] Call bell within reach (if age-appropriate)
|
||||
- [ ] Fall risk assessment completed
|
||||
- [ ] Restraints (if used) appropriate and documented
|
||||
|
||||
## Family-Centered Care
|
||||
|
||||
- [ ] Family updated on plan of care
|
||||
- [ ] Family presence encouraged
|
||||
- [ ] Parent questions addressed
|
||||
- [ ] Developmental care practices implemented
|
||||
- [ ] Quiet time/minimal handling respected
|
||||
|
||||
## Documentation
|
||||
|
||||
- [ ] I&O documented accurately
|
||||
- [ ] Weight documented (if scheduled)
|
||||
- [ ] Vital signs documented per protocol
|
||||
- [ ] All medications documented in MAR
|
||||
- [ ] Care plan updated
|
||||
|
||||
## Issues Identified
|
||||
|
||||
**Issues requiring follow-up:**
|
||||
|
||||
|
||||
|
||||
**Actions taken:**
|
||||
|
||||
|
||||
|
||||
## Signature
|
||||
|
||||
| Role | Name | Signature | Date/Time |
|
||||
|------|------|-----------|-----------|
|
||||
| RN | | | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-SAF-001 Rev 1.0*
|
||||
0
Forms/Sedation-Scoring/.gitkeep
Normal file
0
Forms/Sedation-Scoring/.gitkeep
Normal file
128
Forms/Sedation-Scoring/FRM-SED-001-COMFORT-Scale.md
Normal file
128
Forms/Sedation-Scoring/FRM-SED-001-COMFORT-Scale.md
Normal file
@@ -0,0 +1,128 @@
|
||||
# COMFORT Sedation Assessment Scale
|
||||
|
||||
| Form ID | FRM-SED-001 | Revision | 1.0 |
|
||||
|---------|-------------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Patient Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Patient Name | |
|
||||
| MRN | |
|
||||
| Date of Birth | |
|
||||
| Assessment Date | |
|
||||
| Assessment Time | |
|
||||
| Assessed By | |
|
||||
|
||||
## COMFORT Scale Scoring
|
||||
|
||||
### 1. Alertness
|
||||
|
||||
- [ ] 1 - Deeply asleep (eyes closed, no response to changes)
|
||||
- [ ] 2 - Lightly asleep (eyes mostly closed, occasional response)
|
||||
- [ ] 3 - Drowsy (eyes mostly closed, occasional response to environment)
|
||||
- [ ] 4 - Fully awake and alert
|
||||
- [ ] 5 - Hyperalert (exaggerated responses to stimuli)
|
||||
|
||||
### 2. Calmness/Agitation
|
||||
|
||||
- [ ] 1 - Calm (no agitation, peaceful)
|
||||
- [ ] 2 - Slightly anxious (slightly anxious but easily reassured)
|
||||
- [ ] 3 - Anxious (anxious, not easily reassured)
|
||||
- [ ] 4 - Very anxious (very anxious, resistant to treatment)
|
||||
- [ ] 5 - Panicky (panicky, fighting/pulling at tubes)
|
||||
|
||||
### 3. Respiratory Response (for ventilated patients)
|
||||
|
||||
- [ ] 1 - No spontaneous respirations
|
||||
- [ ] 2 - Spontaneous respirations with little response to ventilator
|
||||
- [ ] 3 - Occasional cough or resistance to ventilator
|
||||
- [ ] 4 - Actively breathes against ventilator
|
||||
- [ ] 5 - Fights ventilator, coughing regularly
|
||||
|
||||
### 4. Physical Movement
|
||||
|
||||
- [ ] 1 - No movement
|
||||
- [ ] 2 - Occasional slight movement
|
||||
- [ ] 3 - Frequent slight movement
|
||||
- [ ] 4 - Vigorous movement limited to extremities
|
||||
- [ ] 5 - Vigorous movement including torso and head
|
||||
|
||||
### 5. Blood Pressure (MAP) Baseline
|
||||
|
||||
**Baseline MAP:** ______ mmHg
|
||||
|
||||
- [ ] 1 - MAP below baseline
|
||||
- [ ] 2 - MAP consistently at baseline
|
||||
- [ ] 3 - Infrequent elevations ≥15% above baseline
|
||||
- [ ] 4 - Frequent elevations ≥15% above baseline
|
||||
- [ ] 5 - Sustained elevation ≥15% above baseline
|
||||
|
||||
### 6. Heart Rate Baseline
|
||||
|
||||
**Baseline HR:** ______ bpm
|
||||
|
||||
- [ ] 1 - HR below baseline
|
||||
- [ ] 2 - HR consistently at baseline
|
||||
- [ ] 3 - Infrequent elevations ≥15% above baseline
|
||||
- [ ] 4 - Frequent elevations ≥15% above baseline
|
||||
- [ ] 5 - Sustained elevation ≥15% above baseline
|
||||
|
||||
### 7. Muscle Tone
|
||||
|
||||
- [ ] 1 - Muscles totally relaxed, no muscle tone
|
||||
- [ ] 2 - Reduced muscle tone
|
||||
- [ ] 3 - Normal muscle tone
|
||||
- [ ] 4 - Increased muscle tone and flexion of fingers and toes
|
||||
- [ ] 5 - Extreme muscle rigidity and flexion of fingers and toes
|
||||
|
||||
### 8. Facial Tension
|
||||
|
||||
- [ ] 1 - Facial muscles totally relaxed
|
||||
- [ ] 2 - Facial muscle tone normal, no facial tension
|
||||
- [ ] 3 - Tension evident in some facial muscles
|
||||
- [ ] 4 - Tension evident throughout facial muscles
|
||||
- [ ] 5 - Facial muscles contorted and grimacing
|
||||
|
||||
## Total Score
|
||||
|
||||
**Total COMFORT Score:** ______ / 40
|
||||
|
||||
## Score Interpretation
|
||||
|
||||
- **8-16**: Over-sedated
|
||||
- **17-26**: Optimal sedation range
|
||||
- **27-40**: Under-sedated
|
||||
|
||||
## Clinical Action
|
||||
|
||||
### Current Sedation
|
||||
| Medication | Dose | Rate |
|
||||
|------------|------|------|
|
||||
| | | |
|
||||
| | | |
|
||||
|
||||
### Action Taken Based on Score
|
||||
- [ ] No change needed
|
||||
- [ ] Increase sedation
|
||||
- [ ] Decrease sedation
|
||||
- [ ] Notify physician
|
||||
- [ ] Other: ____________
|
||||
|
||||
### Comments
|
||||
|
||||
|
||||
|
||||
## Signature
|
||||
|
||||
| Role | Name | Signature | Date/Time |
|
||||
|------|------|-----------|-----------|
|
||||
| RN/RT | | | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-SED-001 Rev 1.0*
|
||||
|
||||
**Reference:** Ambuel B, Hamlett KW, Marx CM, Blumer JL. Assessing distress in pediatric intensive care environments: the COMFORT scale. J Pediatr Psychol. 1992.
|
||||
140
Forms/Sedation-Scoring/FRM-SED-002-NPASS-Scale.md
Normal file
140
Forms/Sedation-Scoring/FRM-SED-002-NPASS-Scale.md
Normal file
@@ -0,0 +1,140 @@
|
||||
# Neonatal Pain, Agitation & Sedation Scale (N-PASS)
|
||||
|
||||
| Form ID | FRM-SED-002 | Revision | 1.0 |
|
||||
|---------|-------------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Patient Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Patient Name | |
|
||||
| MRN | |
|
||||
| Gestational Age | |
|
||||
| Assessment Date | |
|
||||
| Assessment Time | |
|
||||
| Assessed By | |
|
||||
|
||||
## Assessment Instructions
|
||||
|
||||
- Assess infant behavior over 1-2 minutes
|
||||
- Score sedation criteria first (if sedated), then pain/agitation criteria
|
||||
- Note: Premature infants may have muted responses
|
||||
|
||||
## Sedation/Pain Assessment
|
||||
|
||||
### 1. Crying/Irritability
|
||||
|
||||
**Sedation**
|
||||
- [ ] -2: No cry with painful stimuli
|
||||
- [ ] -1: Moans/cries minimally to painful stimuli
|
||||
- [ ] 0: Appropriate crying, not irritable
|
||||
|
||||
**Pain/Agitation**
|
||||
- [ ] +1: Irritable at intervals, consolable
|
||||
- [ ] +2: High-pitched or silent continuous cry, inconsolable
|
||||
|
||||
### 2. Behavior/State
|
||||
|
||||
**Sedation**
|
||||
- [ ] -2: No arousal to any stimuli, no spontaneous movement
|
||||
- [ ] -1: Arouses minimally to stimuli, little spontaneous movement
|
||||
- [ ] 0: Appropriate for gestational age
|
||||
|
||||
**Pain/Agitation**
|
||||
- [ ] +1: Restless, squirming, awakens frequently
|
||||
- [ ] +2: Arching, kicking, constantly awake or minimal sleep
|
||||
|
||||
### 3. Facial Expression
|
||||
|
||||
**Sedation**
|
||||
- [ ] -2: Mouth lax, no expression
|
||||
- [ ] -1: Minimal expression with stimuli
|
||||
- [ ] 0: Relaxed, appropriate facial expression
|
||||
|
||||
**Pain/Agitation**
|
||||
- [ ] +1: Any pain expression intermittent
|
||||
- [ ] +2: Any pain expression continual
|
||||
|
||||
### 4. Extremities/Tone
|
||||
|
||||
**Sedation**
|
||||
- [ ] -2: No grasp reflex, flaccid tone
|
||||
- [ ] -1: Weak grasp reflex, decreased tone
|
||||
- [ ] 0: Relaxed hands/feet, normal tone
|
||||
|
||||
**Pain/Agitation**
|
||||
- [ ] +1: Intermittent clenched toes/fisted hands, increased tone
|
||||
- [ ] +2: Continual clenched toes/fisted hands, body tense
|
||||
|
||||
### 5. Vital Signs (HR, RR, BP, SaO2)
|
||||
|
||||
**Baseline Values:**
|
||||
- HR: ______ bpm
|
||||
- RR: ______ breaths/min
|
||||
- BP: ______ mmHg
|
||||
- SaO2: ______ %
|
||||
|
||||
**Sedation**
|
||||
- [ ] -2: No variability with stimuli, hypoventilation or apnea
|
||||
- [ ] -1: Less than baseline variability, slow or pause in respirations
|
||||
- [ ] 0: Within baseline, no out-of-sync breathing on vent
|
||||
|
||||
**Pain/Agitation**
|
||||
- [ ] +1: SaO2 76-85% with stimulation, quick return to baseline
|
||||
- [ ] +2: SaO2 ≤75% with stimulation, slow return to baseline, out-of-sync with vent
|
||||
|
||||
## Total Score
|
||||
|
||||
**Total N-PASS Score:** ______
|
||||
|
||||
(Range: -10 to +10)
|
||||
|
||||
## Score Interpretation
|
||||
|
||||
- **-10 to -5**: Deep sedation
|
||||
- **-4 to -2**: Light-moderate sedation
|
||||
- **-1 to +1**: Normal sedation/pain management
|
||||
- **+2 to +5**: Mild to moderate pain/agitation
|
||||
- **+6 to +10**: Severe pain/agitation
|
||||
|
||||
## Clinical Action
|
||||
|
||||
### Current Sedation/Analgesia
|
||||
| Medication | Dose | Route | Frequency |
|
||||
|------------|------|-------|-----------|
|
||||
| | | | |
|
||||
| | | | |
|
||||
|
||||
### Action Taken Based on Score
|
||||
- [ ] No change needed
|
||||
- [ ] Increase sedation/analgesia
|
||||
- [ ] Decrease sedation/analgesia
|
||||
- [ ] Notify physician
|
||||
- [ ] Non-pharmacological comfort measures
|
||||
- [ ] Other: ____________
|
||||
|
||||
### Non-Pharmacological Interventions Used
|
||||
- [ ] Swaddling
|
||||
- [ ] Pacifier
|
||||
- [ ] Positioning
|
||||
- [ ] Reduced stimulation
|
||||
- [ ] Skin-to-skin care
|
||||
- [ ] Other: ____________
|
||||
|
||||
### Comments
|
||||
|
||||
|
||||
|
||||
## Signature
|
||||
|
||||
| Role | Name | Signature | Date/Time |
|
||||
|------|------|-----------|-----------|
|
||||
| RN | | | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-SED-002 Rev 1.0*
|
||||
|
||||
**Reference:** Hummel P, Puchalski M, Creech SD, Weiss MG. Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain. J Perinatol. 2008.
|
||||
0
Forms/Ventilator-Weaning/.gitkeep
Normal file
0
Forms/Ventilator-Weaning/.gitkeep
Normal file
@@ -0,0 +1,156 @@
|
||||
# Extubation Readiness Checklist
|
||||
|
||||
| Form ID | FRM-VENT-001 | Revision | 1.0 |
|
||||
|---------|--------------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Patient Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Patient Name | |
|
||||
| MRN | |
|
||||
| Age/DOB | |
|
||||
| Date | |
|
||||
| Time | |
|
||||
|
||||
## Pre-Extubation Assessment
|
||||
|
||||
### Clinical Criteria
|
||||
|
||||
#### 1. Underlying Condition Resolved/Improved
|
||||
- [ ] Yes
|
||||
- [ ] No - Explain: ____________
|
||||
|
||||
#### 2. Hemodynamic Stability
|
||||
- [ ] MAP appropriate for age without significant vasoactive support
|
||||
- [ ] Heart rate stable
|
||||
- [ ] No active bleeding
|
||||
|
||||
**Current Vasoactive Medications:**
|
||||
| Medication | Dose |
|
||||
|------------|------|
|
||||
| | |
|
||||
|
||||
#### 3. Oxygenation
|
||||
- [ ] FiO2 ≤ 0.40 (or ≤ 0.50 for neonates)
|
||||
- [ ] PaO2/FiO2 ratio > 200
|
||||
- [ ] SpO2 > 90% on current settings
|
||||
|
||||
**Current Settings:**
|
||||
- FiO2: ______
|
||||
- PEEP: ______ cmH2O
|
||||
- Latest ABG: pH _____ pCO2 _____ pO2 _____ HCO3 _____
|
||||
|
||||
#### 4. Ventilation
|
||||
- [ ] PaCO2 acceptable for patient
|
||||
- [ ] Peak pressure ≤ 20 cmH2O (or age-appropriate)
|
||||
- [ ] Spontaneous breathing on minimal support
|
||||
|
||||
**Current Settings:**
|
||||
- Mode: ______
|
||||
- Rate: ______
|
||||
- PIP/PS: ______ cmH2O
|
||||
- Spontaneous rate: ______
|
||||
|
||||
#### 5. Spontaneous Breathing Trial (if performed)
|
||||
- [ ] Performed
|
||||
- [ ] Not performed
|
||||
|
||||
**If performed:**
|
||||
- Duration: ______ minutes
|
||||
- Mode: [ ] T-piece [ ] CPAP [ ] PS/CPAP
|
||||
- Tolerated: [ ] Yes [ ] No
|
||||
|
||||
#### 6. Airway Protection
|
||||
- [ ] Adequate cough reflex
|
||||
- [ ] Appropriate gag reflex
|
||||
- [ ] Manageable secretions
|
||||
- [ ] Alert/appropriate neurological status
|
||||
|
||||
**Secretion Description:**
|
||||
- Amount: [ ] Minimal [ ] Moderate [ ] Copious
|
||||
- Character: ____________
|
||||
|
||||
#### 7. Sedation Status
|
||||
- [ ] Minimal or weaning sedation
|
||||
- [ ] Able to follow commands (if age-appropriate)
|
||||
|
||||
**Current Sedation:**
|
||||
| Medication | Dose | Last Given |
|
||||
|------------|------|------------|
|
||||
| | | |
|
||||
|
||||
#### 8. Metabolic Status
|
||||
- [ ] Adequate nutrition
|
||||
- [ ] No significant electrolyte imbalances
|
||||
- [ ] Normal temperature
|
||||
|
||||
**Latest Labs:**
|
||||
- Na: _____ K: _____ Cl: _____ HCO3: _____
|
||||
- Ca: _____ Mg: _____ Phos: _____
|
||||
|
||||
#### 9. Post-Extubation Plan
|
||||
- [ ] Non-invasive support planned: ______
|
||||
- [ ] High-flow nasal cannula available
|
||||
- [ ] Room air trial planned
|
||||
- [ ] RT available at bedside for extubation
|
||||
|
||||
### Special Considerations
|
||||
|
||||
#### For Neonates:
|
||||
- [ ] Caffeine on board (if applicable)
|
||||
- [ ] Weight > 500g (or institution-specific threshold)
|
||||
- [ ] Postmenstrual age considerations addressed
|
||||
|
||||
#### For Long-Term Ventilation:
|
||||
- [ ] Airway evaluation performed (if >7 days intubated)
|
||||
- [ ] Consider subglottic edema risk
|
||||
- [ ] Dexamethasone considered (if appropriate)
|
||||
|
||||
## Contraindications to Extubation
|
||||
|
||||
- [ ] Active seizures
|
||||
- [ ] Neuromuscular blockade
|
||||
- [ ] Recent airway surgery
|
||||
- [ ] Significant facial/airway trauma or edema
|
||||
- [ ] Other: ____________
|
||||
|
||||
## Physician Review
|
||||
|
||||
**Attending Physician Notified:** [ ] Yes [ ] No
|
||||
|
||||
**Extubation Approved:** [ ] Yes [ ] No
|
||||
|
||||
**If No, reason:** ____________
|
||||
|
||||
## Extubation Procedure
|
||||
|
||||
**Extubation Date/Time:** ____________
|
||||
|
||||
**Post-Extubation Support:**
|
||||
- [ ] Room air
|
||||
- [ ] Nasal cannula: ______ L/min
|
||||
- [ ] High-flow nasal cannula: ______ L/min, FiO2: ______
|
||||
- [ ] CPAP: ______ cmH2O
|
||||
- [ ] BiPAP: IPAP ______ EPAP ______
|
||||
|
||||
**Immediate Post-Extubation Assessment (within 1 hour):**
|
||||
- SpO2: ______ %
|
||||
- RR: ______ breaths/min
|
||||
- HR: ______ bpm
|
||||
- Work of breathing: [ ] Minimal [ ] Moderate [ ] Severe
|
||||
- Stridor: [ ] None [ ] Mild [ ] Moderate [ ] Severe
|
||||
|
||||
## Signatures
|
||||
|
||||
| Role | Name | Signature | Date/Time |
|
||||
|------|------|-----------|-----------|
|
||||
| RN | | | |
|
||||
| RT | | | |
|
||||
| MD/NP | | | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-VENT-001 Rev 1.0*
|
||||
Reference in New Lab Ticket
Block a user