Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location
  • Documented Nurse

  • MRN

  • Length in ED

ED Assessment and Documentation Audit

Nursing Documentation

  • Patient identification Verified

  • Ordered medication: Acknowledge and carried out

  • IV Medication associated to Alaris pump

  • Dual signatures performed before procedure

  • John Depency tools documented accurately per shift or any changes of patient condition

  • Patient's physical assessment done accurately

  • All stat ordered carried out accordingly

  • Intake and output chart documented accurately

  • Critical result escalated and documented accurately

  • Procedural consent secured for each procedures


  • All sections of NCP appropriately completed

  • Patient assessed/ Reassessed

  • Nursing Diagnosis according to NANDAi

  • Measurable Goals are SMART

  • Goals in line with the nursing diagnosis

  • Proof of carrying out of planned care

  • There is evaluation of measurable goal

  • Age specific assessment completed

  • Psychosocial assessment completed


  • Use of appropriate and complete assessment tool. Ensure correct total score and interventions are ticked

  • All patients are assessed for risk of falling on admission, transfer, following a change in condition and/or post fall

  • Reassessment of falls should be done as per guidelines stipulated in the tool

  • A plan of care including fall prevention and precautions is to be implemented. Ensure preventive actions and interventions are ticked

  • Provide education on Standard Falls Precaution upon admission and as indicated

  • Post Fall Management: Recording fall in notes, completing a Datix report


  • Initial pain screening upon admission

  • Pain screening at specified interval (ex. Postoperative), vital signs or change of condition

  • Use of appropriate KFMC approved pain assessment tool (Wong Baker, Visual Numeric, CRIES, FLACC, MCPOT)

  • Complete pain assessment and reassessment for patients in pain

  • Provide assessment and management education upon admission and as indicated


  • Patient is screened by nurse within 24 hours upon admission using the approved nutritional screening form

  • Patient's risk category ticked

  • Relevant patient risk factors ticked

  • Patient's height and weight recorded

  • Patient at risk referred and seen within 24 to 72 hours name of dietician informed, date and time of referral

  • Patients not at risk is referred within 7 days of admission (date of referral written)


  • Patient's educational abilities and barriers are assessed and documented

  • Patient or family educational needs are assessed and documented

  • Patients and families are educated about: Participation in Care Plan

  • Patients and families are educated about: Infection control practices and personal hygiene

  • Patients and families are educated about: Required treatments and procedures

  • Patients and families are educated about: Use of Medical Equipment or appliances

  • Patients and families are educated about: Necessary medications, the frequency, potential sideeffects and fooddrug interactions

  • Patients and families are educated about: Rationale and benefits of any dietary restrictions

  • Patients and families are educated about: Pressure ulcer prevention

  • Patient educated using appropriate tools or methods

  • Evaluation of patient/ family's response to education (action plan generated if understanding unsatisfactorily)

  • Completeness of the form


  • All related lines are documented

  • Assessment for line related documentation are documented accurately

  • Wounds are documented accurately


  • Skin assessment documented accurately for initial assessment

  • Intervention done to prevent pressure injury


  • POCT Blood glucose documented as per workflow

  • POCT Urine Analysis documented as per workflow

  • POCT Urine pregnancy test documented as per workflow

  • POCT RSV documented as per workflow


  • All communication between providers documented in the provider notification

  • Nurse In charge review the documentation every 12 hour of shift or more

  • Endorsement between shift documented and receiving with acknowledgement

  • Endorsement during shift documented and receiving with acknowledgement by the 2nd nurse

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