Patient Name:



|Patient Name: |Agency: |

|Review Date: |Admission Date: |

|Reviewer: |Hospitalization Date: |

|Primary Clinician: |Date last SN visit: |

CHF Hospitalization Audit Tool 2004 (HCANH)

| |Yes |No |N/A |Comments |

|Was the admission weight measured & documented? | | | | |

|Documentation supports evidence of daily weights being done? | | | | |

|Were lung sounds assessed at every SN visit? | | | | |

|Was SOB/ dyspnea assessed at every SN visit? | | | | |

| | | | | |

|Nocturnal | | | | |

| | | | | |

|Cough | | | | |

| | | | | |

|Oxygen compliance | | | | |

|Were B/P, P, R assessed and recorded at every SN visit? | | | | |

|Documentation is present in the record of the patient/ caregiver ‘s response to medication | | | | |

|teaching | | | | |

|Documentation is present in the record of the patient/ caregiver ‘s verbal response to teaching| | | | |

|of ordered diet. | | | | |

|Was the MD notified when: | | | | |

|Weight increased 2 -3 lbs. in 24° or 5 lbs. in 5 days | | | | |

| | | | | |

|Worsening breath sounds from previous SN Visit | | | | |

| | | | | |

|Increased SOB or dyspnea from baseline | | | | |

| | | | | |

|Increased cough | | | | |

| | | | | |

|Non-compliance with Care plan | | | | |

Updated 2/25/04

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