Nursing Audit Checklist

• Audit on

  Date

• Prepared by

• Location
  Address

• Room/Unit #

• Admissions date

  Date

Medical Record

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

  Yes

  No

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

  Yes

  No

• Treatment admin. records signed for.

  Yes

  No

• Medication admin. records (MAR) signed.

  Yes

  No

• Immunizations documented properly/done.

  Yes

  No

• Weights charted monthly per order.

  Yes

  No

• Does the documentation demonstrate:

• • Skilled observation and monitoring

  Yes

  No

• • Assessment

  Yes

  No

• • Progress notes

  Yes

  No

• • Other

  Yes

  No

• What else do the documentation demonstrate:

• Is the care plan:

• Accurate and up to date?

  Yes

  No

• Measurable goals?

  Yes

  No

• Relevant problems?

  Yes

  No

• Specific problems or potential problems identified and planned interventions identified?

  Yes

  No

• 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.

  Yes

  No

• Proper evaluation dates and follow-ups.

  Yes

  No

• Proper signatures on care plan.

  Yes

  No

• Care planning reflects MDS and other assessments.

  Yes

  No

• Evidence of teaching, training, and outcomes clearly noted.

  Yes

  No

Special Needs

• Thickened liquids/dysphagia

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

  Yes

  No

• Water at bedside.

  Yes

  No

• Fall risks

• Fall risk evident.

  Yes

  No

• Care planned.

  Yes

  No

• Wounds

• Wound care protocol followed/proper forms completed.

  Yes

  No

• Care planned.

  Yes

  No

• Pain management

• Protocol/forms followed (assessment and outcome).

  Yes

  No

• Care planned.

  Yes

  No

• MAR completed.

  Yes

  No

• Initial and ongoing pain assessments done.

  Yes

  No

• Equipment in room

• Respiratory, feeding pump equipment labeled/tagged.

  Yes

  No

• IVs dated, labeled.

  Yes

  No

• Wound dressings, IV site dated and signed.

  Yes

  No

• Resident appearance

• Properly positioned. WC, bed.

  Yes

  No

• Appears clean, appropriate dress.

  Yes

  No

• Any complaints/concerns.

  No

  Yes

Completion

• Comments/Suggestions

• Auditor name and signature

  Sign