Nursing Audit

Medical Record

Admission assessment is fully completed, signed by RN (co-sign).

All other assessments done: pain, fall, skin, etc.

Treatment admin. records signed for.

Medication admin. records (MAR) signed.

Immunizations documented properly/done.

Weights charted monthly per order.

Does the documentation demonstrate:

• Skilled observation and monitoring

• Assessment

• Progress notes

• Other

What else do the documentation demonstrate:

Is the care plan:

Accurate and up to date?

Measurable goals?

Relevant problems?

Specific problems or potential problems identified and planned interventions identified?

Indication of daily or more frequent monitoring of vital signs, lung sounds, bowel sounds, skin condition, nutritional status, hydration, mental status, and mobility as it relates to instability or possible changes in condition to help identify if changes in nursing care are indicated.

Proper evaluation dates and follow-ups.

Proper signatures on care plan.

Care planning reflects MDS and other assessments.

Evidence of teaching, training, and outcomes clearly noted.

Special Needs

Thickened liquids/dysphagia

Proper notation by the door (if permitted by state); proper protocol followed.

Water at bedside.

Fall risks

Fall risk evident.

Care planned.


Wound care protocol followed/proper forms completed.

Care planned.

Pain management

Protocol/forms followed (assessment and outcome).

Care planned.

MAR completed.

Initial and ongoing pain assessments done.

Equipment in room

Respiratory, feeding pump equipment labeled/tagged.

IVs dated, labeled.

Wound dressings, IV site dated and signed.

Resident appearance

Properly positioned. WC, bed.

Appears clean, appropriate dress.

Any complaints/concerns.



Auditor name and signature
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.