2017 Memorial Emergency Epic Documentation Audit Tool Name: ED Visit Date: ED CSN # lagnosis. imo pees ‘Was the folowing | Yes | No NIA secumenied? | ESI complete and | i: | the assessment appropriate for chief complaint? | “ Reassessments documented: Change in patient's status? Pain level reassessed after Intervention? - When there is a change + patients vital sions? ‘As indicated by the pallants ‘conditon/reatmentprocedure gon decbergeladmit fromthe, | { ‘At change of shif, transfer or. | | Vital signs taken according to ‘vital sign recommendations ‘based on ES! during stay? Vitel signs documented within 90 © minutes of discharge ot ‘admission? >If patient admitted, IRS or: rPEWS | completed? : Epic Audit Toolinsertion? Pain level at _schargeladmission? Overall grade~ ee ieee eee ‘Minimal Compliance | | Below Standards | I Comments Epic Audit Tool