Download AUDIT TOOL - NSW Health

AUDIT TOOL
Insertion & Confirmation of Correct Placement of
Nasogastric and Orogastric Tubes
Facility: Click here to enter text.
Ward/Emergency Department: Click here to enter text.
MRN: Click here to enter text.
Gastric Tube inserted
Indications for
insertion
Adverse outcome/s for
patient
Time: __ __: __ __ (24 hour clock)
Date: Click here to enter a date.
Nutritional needs
☐
Administering medications
☐
☐
Rehydration
☐
Decompression of the stomach
Yes ☐
No ☐
Not documented ☐
If so, please indicate type of adverse event: Click here to enter text.
Documentation
Was the following documented in the
child’s progress notes / nursing care plan
Click here to enter text.
Type/Size of tube
Yes ☐
No ☐
Not documented ☐
External length of tube at nostril
Yes ☐
No ☐
Not documented ☐
Aspirate obtained
Yes ☐
No ☐
Not documented ☐
pH of aspirate
Yes ☐pHClick here to enter text. No ☐ Not documented
Attempts at insertion
Confirmation of Placement
Placement confirmed by:
Number Click here to enter text.
Not documented ☐
pH indicator strip
Yes ☐
No ☐
Not documented ☐
X-ray or Ultrasound
Yes ☐
No ☐
Not documented ☐
Other method
Yes ☐ State Which Click here to enter text.
Post insertion, observations documented
on specific observation chart i.e. SPOC,
EDSPOC, SNOC, eMR
Yes ☐
No ☐
Not documented ☐
Placement re-confirmed prior to the
administration of fluids or medications
Yes ☐
No ☐
Not documented ☐
If continuous feeds, was placement
reconfirmed at least once per shift
Yes ☐
No ☐
Not documented ☐
Comments:
Click here to enter text.
Name of Auditor: Click here to enter text.
Designation: Click here to enter text.
THIS IS NOT A MEDICAL RECORD FORM
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AUDIT TOOL
Insertion & Confirmation of Correct Placement of
Nasogastric and Orogastric Tubes
COMPLETING THE AUDIT TOOL
This audit tool accompanies the Insertion & Confirmation of Correct Placement of Nasogastric and
Orogastric Tubes
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All dates are in DD/MM/YY format.
All times are in HH:MM 24 hour clock format.
All fields are mandatory and N/A is provided where required.
Please use the comments box to record information which may assist in the data analysis. This
includes explanations of blank fields etc. Do not use the comments box as a pathology or medical
record.
 The name of auditor and designation boxes are to record the name of the person completing the
form.
THIS IS NOT A MEDICAL RECORD FORM