Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • 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?

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