Nursing Audit Checklist Format

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Nursing Audit Checklist Format

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Nursing Audit

Medical Record

Admission assessment is fully completed, signed by RN (co-sign).

Yes No

All other assessments done: pain, fall, skin, etc.

Yes No

Treatment admin. records signed for.

Yes No

Medication admin. records (MAR) signed.

Yes No

Immunizations documented properly/done.

Yes No

Weights charted monthly per order.

Yes No

Does the documentation demonstrate:

• Skilled observation and monitoring

Yes No

• Assessment

Yes No

• Progress notes

Yes No

• Other

Yes No

What else do the documentation demonstrate:

Is the care plan:

Accurate and up to date?

Yes No

Measurable goals?

Yes No

Relevant problems?

Yes No

Specific problems or potential problems identified and planned interventions identified?

Yes No

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.

Yes No

Proper evaluation dates and follow-ups.

Yes No

Proper signatures on care plan.

Yes No

Care planning reflects MDS and other assessments.

Yes No

Evidence of teaching, training, and outcomes clearly noted.

Yes No

Special Needs

Thickened liquids/dysphagia

Proper notation by the door (if permitted by state); proper protocol followed.

Yes No

Water at bedside.

Yes No

Fall risks

Fall risk evident.

Yes No

Care planned.

Yes No

Wounds

Wound care protocol followed/proper forms completed.

Yes No

Care planned.

Yes No

Pain management

Protocol/forms followed (assessment and outcome).

Yes No

Care planned.

Yes No

MAR completed.

Yes No

Initial and ongoing pain assessments done.

Yes No

Equipment in room

Respiratory, feeding pump equipment labeled/tagged.

Yes No

IVs dated, labeled.

Yes No

Wound dressings, IV site dated and signed.

Yes No

Resident appearance

Properly positioned. WC, bed.

Yes No

Appears clean, appropriate dress.

Yes No

Any complaints/concerns.

No Yes

Completion

Comments/Suggestions

Auditor name and signature

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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.