Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location
  • Documented Nurse

  • MRN

  • Length in ED

ED Assessment and Documentation Audit

Patient Identification

  • Patient identification Verified (BCMA Scanning)

CTAS and Acuity

  • CTAS level are appropriately selected on arrival

  • CTAS Level are appropriately selected in case of changed of patient conditions or acuity

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

  • Completion of the nursing acuity John Dependency each shift

Physical Assessment

  • Patient's physical assessment done accurately

  • Physical reassessment documented in each shift and if change of patient condition

  • Completeness of the physical assessment in each entry


  • Ordered medication: Acknowledge and carried out

  • Medications are administered on time following the KFMC policy on medication administration

  • IV Medication associated to Alaris pump

  • Dual signatures performed before procedure

  • All stat ordered carried out accordingly

  • For late administrations - reason for late administration is documented in the nurses notes

  • Medication dual sign off


  • 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

  • Care plan is updated and evaluated every shift


  • 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

  • COmpleteness of the data entry is observed


  • 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

  • Completeness of the data entry is observed


  • 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 side effects and food drug 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


  • Patient is screened by the nurse within 24 hours of admission using the screening form

  • Patients subsequently requiring social worker intervention, the patient is directly referred – documented in the nurse’s notes

  • Patients that needs referral are referred accordingly – referral is documented in the nurse’s notes

  • Completeness of the data entry is observed


  • All related lines are documented

  • Assessment for line related documentation are documented accurately


  • Patients who present to the emergency department and outpatient areas for a period longer than 6 hours, performed pressure risk assessment

  • Skin assessment documented accurately for initial assessment

  • Intervention done to prevent pressure injury

  • Reassess patient according to risk factor, change of patient condition and transfer

  • All pressure ulcers reported on the Datix incident reporting system and documented in the Daily Care Safety Checklist

  • Appropriate preventive measures implemented for at risk patients


  • Intake and output chart documented accurately


  • 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

PROCEDURAL WITHOUT SEDATION (E.g.: Biopsy, PICC Line insertion, Lumbar puncture e.t.c)

  • Valid and completion of informed consent are documented and available

  • Pre Verification Procedural completed

  • Surgical Safety Checklist (Sign in, Time in and Time Out) are completed for updated version


  • Valid general consent available in the patient's file

  • Consent sign by the patient or legal patient's guardian

  • Signed by 2 witnesses or as needed per policy

  • Reason of patient unable to sign documented in the consent

  • All other information are completed

  • No abbreviations used


  • 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

  • Handover template is used (ISBAR) in documenting handover

  • Handover is done whenever responsibility for the care of a patient is transferred to another healthcare provider and documented

  • Handover template is completely filled up, no unapproved abbreviations used


  • Critical result escalated and documented accurately


  • Blood type and screen collected with dual signatures documented

  • Consent for blood and blood product is secured and completed

  • Baseline vital signs taken and recorded prior to obtaining the blood products from the blood bank

  • Patient is monitored for early signed and symptoms of transfusion reaction every 15minutes for the first hour, every 30 minutes in the second hour and hourly thereafter

  • Product type , blood group and rhesus factor, volume, transfused and rate, product identification number, patient vital sign, and patient assessment finding and tolerance to the procedure documented in the nurses notes.


  • Patient valuables and belonging upon arrival to the room checked and documented

  • Disclaimers on valuable and belonging completed upon the patient's arrival in the ward

  • Patient and family education on patient valuables and belongings given and documented.

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