Audit

Quick Reference Phone Numbers
Command Center 5-3333 Dana Moore- cell 443-250-7398
Command Center Fax Number: 4-1115 Susan Franklin cell 443-804-0630
Tameria Joy- cell: 410-227-4515
Email: grp-CommandCenter@exchange.johnshopkins.edu Veronica Johnson- cell: 443-858-5581, pager 410-434-1504
Surveyor Team

Surveyor Name/ Title:
Escort Name:
Scribe Name:

Survey Area (Note when location changes)- Questions/Issues/Suggestions made by Surveyor
Summary Notes and PATIENT NAME/HISTORY# BEING TRACED

Name of any staff interviewed: Name,Role, Badge #

MR# of charts reviewed:

Additional Information

Summary of Major Concerns/Issues

Positive/Compliments to Individuals

Additional Notes

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.