Nursing audit is the process of determining the quality of nursing care by reviewing clinical records made by healthcare professionals. It helps ensure consistent quality patient care and uncover areas for improvement. Use this nursing audit checklist to confirm compliance with proper nursing documentation and check patient care provided to patients (currently in admission or discharged).
Admission assessment is fully completed, signed by RN (co-sign).
All other assessments done: pain, fall, skin, etc.
Treatment admin. records signed for.
Medication admin. records (MAR) signed.
Immunizations documented properly/done.
Weights charted monthly per order.
Does the documentation demonstrate:
• Skilled observation and monitoring
• Assessment
• Progress notes
• Other
What else do the documentation demonstrate:
Is the care plan:
Accurate and up to date?
Measurable goals?
Relevant problems?
Specific problems or potential problems identified and planned interventions identified?
Indication of daily or more frequent monitoring of vital signs, lung sounds, bowel sounds, skin condition, nutritional status, hydration, mental status, and mobility as it relates to instability or possible changes in condition to help identify if changes in nursing care are indicated.
Proper evaluation dates and follow-ups.
Proper signatures on care plan.
Care planning reflects MDS and other assessments.
Evidence of teaching, training, and outcomes clearly noted.
Special Needs
Thickened liquids/dysphagia
Proper notation by the door (if permitted by state); proper protocol followed.
Water at bedside.
Fall risks
Fall risk evident.
Care planned.
Wounds
Wound care protocol followed/proper forms completed.
Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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