Audit

Does the residents care file include a Nursing assessment completed within 1 week of his/her admission?

Does the Nursing assessment record the involvement of the key worker in the assessment process?

Does the clinical file include nursing care plans written for the resident within the last 3 months?

Has the residents care plans been evaluated/re written in the last month?

Does the residents care file include a completed admission proforma?

Does the care file include a current up to date photograph of the resident?

Does the care file include the original referral documents for the resident?

Does the care file include a thorough resident history?

Does the care file have a resident personal possessions inventory?

Does the care file have a completed admission checklist?

Does the care file nursing assessment include or evidence the involvement of the resident?

If the resident was not involved in the assessment process is the reason clearly documented?

Does the care file include nursing care plans written for the patient in the last 3 months?

Dot e care plans reflect the individual needs for the resident?

Do the current care plans include details of the residents wishes regarding the involvement of a relative or friend in their care?

Are all parts of the care plans legible and written in black ink?

Are the care plans signed and dated by the key worker?

Do the residents continuation notes reflect that there has been a named nurse 1:1 session in the past week?

If the resident has mental health needs are these reflected in a care plan?

Does the resident have a current medication care plan in situ?

If the resident is on prn medication has this been reflected in a care plan?

Is the residents care file maintained and in good condition, capable of holding all the required documents safely?

Are records kept in chronological order?

Are the clinical notes free from gaps between entries?

Does the care file have appropriate risk assessments in place that are be spoked to the individual?

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.