documentation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

COMPETENCY 14

• Documentation

DEMONSTRATES

• The ability to accurately record information about a patient in a timely manner.

PERFORMANCE CRITERIA

• 1. Identifies Indications for documentation in the patients chart/record (2.5,9.2)

  Yes

  No

  N/A

• 2. Uses appropriate medical terminology and approved abbreviations<br>and acronyms (1.1,2.2,2.6,4.2)

  Yes

  No

  N/A

• 3. Content is relevant and accurate (1.2,1.3,2.2,2.5,2.6,4.4,5.3,6.1,10.2)

  Yes

  No

  N/A

• 4. Adheres to legal requirements (1.1,1.2)

  Yes

  No

  N/A

• 5. Demonstrates ability to effectively use the facilities ' standard<br>forms (1.1,1.2,10.2)

  Yes

  No

  N/A

• 6. Demonstrates ability to link theory to practice (3.2,4.1,4.2)

  Yes

  No

  N/A

STUDENT

EDUCATOR

DATE