Title Page

  • Audit on

  • Prepared by

  • Location
  • Room/Unit #

  • Admissions date

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.

  • Wounds

  • 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.


  • Comments/Suggestions

  • Auditor name and signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.