Date and Time of Audit:


Auditor Name:

Miscellaneous Findings:

Other Noncompliant Findings?

Chart Review
Date of Encounter

Patient MRN:

Provider Name:

Home Med List

Home Medication List is created or edited?

Staff state process to assure patient/family receive an updated Home
Medication List at end of visit--After Visit Summary (AVS) at check-out

The provider reviewed the med list in the visit.

Problem and Allergy List

An up-to-date problem list is in the medical record

An up-to-date allergy list is in the medical record. If no allergies, then the allergy list states none or no allergies.

Patient Rights

Patient's preferred language to receive health care information is documented

Patient Education

Learning Needs Evaluation completed and documented

Keeping You Safe During Surgery and Procedures provided to patient prior to

Patient education provided during visit is documented in progress note or
patient instructions

Patient education on the After Visit Summary (AVS)


Pain documented for the patient visit (Required for visits with a prescriber)

Prescriber addressed pain in their note if pain >3 or if the patient desires to have pain addressed during the visit


Staff can speak to process for assisting when to obtain a MOLST and where a provider can find it

Orders Requiring Co-Signature

All orders requiring co-signature were signed by the authorized provider within
3 business days (NIPO's, Protocols and Verbal orders)

Informed Consent/Procedures

All procedures that require an informed consent have an informed consent completed and scanned into the medical record

Informed consent is signed, dated, timed by authorized provider, witness and patient

Patient's first and last name, and procedure being performed are on pages one and two of informed consent

All sections of informed consent form completed

If sedation administered, sedation consent completed

Timeout documented

The detailed post op note is present and finalized within 7 days post procedure.

All of the required elements for the brief op note plus:
Detailed description of procedure
Clinical stage of tumor, as appropriate

. Brief op note documented with all required elements immediately after procedure: Surgeon and assistant names
Procedure performed Description of findings Post-op diagnosis
Estimated blood loss- if applicable
Specimens removed- if applicable

Provider Visit Documentation

Encounter closed within 14 days

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.