• Conducted on

  • Document No.

  • Date of Out-patient Visit

  • Location / Clinic Name
  • Provider Name and Number

Staff Interviewed

  • Prepared by


  • Patient identifiers documented on each page (For paper record: each page clearly identified with at least patient name and date of birth. For electronic record, may find in EPR Extender).

  • Each signature dated and timed

  • Each credentialed provider signature had ID #

  • No prohibited abbreviations noted

  • All entries legible (applies to paper record only)

  • History and/or relevant findings documented (Components of ambulatory H&P include history, physical examination, relevant laboratory data, diagnosis and plan for care)

  • Follow-up visit to same provider included a brief interval history describing significant issues, assessment and follow-up plan

  • All verbal orders signed within the next calendar day (applies to paper record only)

  • Results of tests ordered present (Results of tests ordered, such as pathology, x-rays, labs, etc., are present for the most current visit or from the previous visit depending on the time frame of the record review)

  • An up-to-date PAM list was in EPR and contained any significant medical diagnoses and conditions

  • An up-to-date PAM list was in EPR and contained any significant operative and invasive procedures

  • An up-to-date PAM list was in EPR and contained any adverse drug reactions

  • An up-to-date PAM list was in EPR and contained any current medications, over-the counter medications and herbal preparations

Medication Reconciliation

  • A complete home medication list was in the chart (Read the clinic note for the audited visit and assure that a complete medication list is present. If a medication appears on the list that the patient is obviously no longer taking or a medication has been omitted, then select no. If the medication list is complete, then select yes. If patient is not taking any medications, select N/A)

  • Staff verbalized the process to assure that patient/family was given a complete medication list if the medication list was edited

Informed Consent

  • Signed, dated, and timed by Provider

  • Signed, dated and timed by Patient

  • Signed, dated and timed by Witness

  • All sections/blanks on form completed

Plan of Care/Education

  • Care plan/goals on chart

  • Patient/family education consistent with services provided

  • Patient/Family's understanding of instructions/education documented

Pain Screening

  • Pain screen documented (Could be the pain score from scanned into medical record, provider addressing pain in the clinic note, or other documentation of patient's pain being addressed at the visit)

  • If pain rating >3 (numerical) or >1 (Faces) or if patient desires to have pain addressed during visit, pain assessment and/or intervention documented

Patients Rights

  • No breaks in patient confidentiality noted (sign-in sheets, logged on computer screens, open charts, conversations, inappropriate PHI disposal)

  • Patient Bill of Rights displayed in public waiting area

  • Partnership Pledge displayed in waiting area

Medication Safety

  • Prescription pads were tamper-proof

  • Prescription pads secured

  • Medication room and medications secured. Anesthesia and medication carts auto locked in 60 seconds.

  • Refrigerator Bins: Medications refrigerator had separate bins for insulin, neuromuscular blocking agents (procedure areas only) as well as "return to pharmacy" bin

  • Multi-use vials within date (appropriately dated with opening and expiration dates)

  • Drug sample policy followed: Security of samples and maintenance logs

Crash Carts and Warming Cabinets

  • Daily checks conducted per policy

  • Emergency Drug Box locks checked daily and recorded on log.

  • Emergency oxygen available

  • Warmers blanket or IV fluid) set to not exceed 110 degrees F. Assure IV fluids not warmed in blanket warmers and were dated and timed (not to exceed 72hours in a warmer)


  • Staff checked two patient identifiers (name and date of birth) and compared them to source document (lab label, requisition, MAR) when giving med, obtaining specimens or before procedure (if directly observed, staff verbalized when to use 2 pt., identifiers and which 2 identifiers to use

  • Staff verbalized how Critical Action Values (CAVs) are received and handled

  • Staff verbalized procedure for broken equipment handling (PSN Orange Tag vs. Broken Equipment Equipment Tag)

  • Inspect sample of medical equipment for clinical engineering services tag and cleanliness

  • Staff verbalized how it is known that clinic equipment is clean and ready for use.

  • Clean and dirty equipment stored separately

  • Staff verbalized knowledge of standard precaution

  • Protective equipment available and staff aware of location

  • Staff verbalized appropriate use of protective equipment (goggles, gloves, N95s, PAPRs)

  • Staff know how to access Emergency Response Team

  • Staff verbalized/demonstrated how to access MSDS sheets on the HSE website or Joint Commission intranet site

  • Staff verbalized/demonstrated how to locate Emergency & Disaster references

  • Staff verbalized contact time for Super Sanicloth and Oxyvir

  • Staff verbalized procedure for management of a chemical or hazardous spill

  • Staff aware of PI projects for clinic

  • Quality controls in place for Point of Care Testing

Other Comments

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.