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Document care quality with this nursing audit checklist format

A nursing audit checklist format 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).
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Nursing Audit
Medical Record
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.
Wound care protocol followed/proper forms completed.
Care planned.
Pain management
Protocol/forms followed (assessment and outcome).
Care planned.
MAR completed.
Initial and ongoing pain assessments done.
Equipment in room
Respiratory, feeding pump equipment labeled/tagged.
IVs dated, labeled.
Wound dressings, IV site dated and signed.
Resident appearance
Properly positioned. WC, bed.
Appears clean, appropriate dress.
Any complaints/concerns.
Auditor name and signature
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Nursing Audit Checklist: A Practical Format for Evaluating Performance

A nursing audit checklist is a useful tool for nursing staff to use when assessing the quality of care provided to patients. It helps to ensure that all areas of patient care are addressed and that any potential gaps in care are identified and addressed as necessary.

The checklist includes a variety of items that must be reviewed and assessed by the nursing staff during an audit. The items typically include assessment of patient care, documentation of medical records, medication management, patient safety, patient education, and other areas related to patient care.

The nursing audit should be tailored to the specific needs of the nursing staff, facility, and patient population. Some items may be applicable to all patients, while others may only be applicable to specific types of patients or situations.

By having a nursing audit checklist in place, the nursing staff can quickly assess any areas of concern, identify potential problems and gaps in care, and take action to ensure that the highest quality of care is provided to all patients.

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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