Nursing Documentation Audit Tool

Title Page

Sample 1

MRN
Ward/Unit
Month
Nursing Assessment completed
Initial patient assessment (V/S, GCS, Risk Assessment Screening) timely documented (within two (2) hours from commencement of the shift and completed within 4 hours
Vital Signs timely documented
24 hours Intake and Output documented
Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented
Patient contraptions (LDAs) assessed , bundle timely documented and completed
Purposeful Rounding timely done and completed
Daily Cares Safety completed
Device Cares Completed
Braden Scale=Pressure Injury Risk Assessment documented and completed
SSKIN assessment completed
Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in Avatar)
Morse Fall Screening completed
Functional Screening done on Admission
Psychocial screening done on Admission
Nursing Notes timely documented using the standard Nursing Handover template in Epic
Nursing Care Plan timely documented
Patient Goals documented on Admission
Patient and Family Education
Patients preference list completed on admission
Shift Required documentation completed
Zero dots in Metrics (for this specific ) patient; Note: If metrics cannot be zeroed- justification must be entered timely in the metrics review

Sample 2

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MRN
Ward/or Unit
Month
Nursing Assessment completed
Initial patient assessment (V/S, GCS, Risk Assessment Screening) timely documented (within two (2) hours from commencement of the shift and completed within 4 hours
Vital Signs timely documented
24 hours Intake and Output documented
Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented
Patient contraptions (LDAs) assessed , bundle timely documented and completed
Purposeful Rounding timely done and completed
Daily Cares Safety completed
Device Cares Completed
Braden Scale=Pressure Injury Risk Assessment documented and completed
SSKIN assessment completed
Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in Avatar)
Morse Fall Screening completed
Functional Screening done on Admission
Psychocial screening done on Admission
Nursing Notes timely documented using the standard Nursing Handover template in Epic
Nursing Care Plan timely documented
Patient Goals documented on Admission
Patient and Family Education
Patients preference list completed on admission
Shift Required documentation completed
Zero dots in Metrics (for this specific ) patient; Note: If metrics cannot be zeroed- justification must be entered timely in the metrics review

Sample 3

MRN
Ward/or Unit
Month
Nursing Assessment completed
Initial patient assessment (V/S, GCS, Risk Assessment Screening) timely documented (within two (2) hours from commencement of the shift and completed within 4 hours
Vital Signs timely documented
24 hours Intake and Output documented
Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented
Patient contraptions (LDAs) assessed , bundle timely documented and completed
Purposeful Rounding timely done and completed
Daily Cares Safety completed
Device Cares Completed
Braden Scale=Pressure Injury Risk Assessment documented and completed
SSKIN assessment completed
Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in Avatar)
Morse Fall Screening completed
Functional Screening done on Admission
Psychocial screening done on Admission
Nursing Notes timely documented using the standard Nursing Handover template in Epic
Nursing Care Plan timely documented
Patient Goals documented on Admission
Patient and Family Education
Patients preference list completed on admission
Shift Required documentation completed
Zero dots in Metrics (for this specific ) patient; Note: If metrics cannot be zeroed- justification must be entered timely in the metrics review

Sample 4

MRN
Ward/or Unit
Month
Nursing Assessment completed
Initial patient assessment (V/S, GCS, Risk Assessment Screening) timely documented (within two (2) hours from commencement of the shift and completed within 4 hours
Vital Signs timely documented
24 hours Intake and Output documented
Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented
Patient contraptions (LDAs) assessed , bundle timely documented and completed
Purposeful Rounding timely done and completed
Daily Cares Safety completed
Device Cares Completed
Braden Scale=Pressure Injury Risk Assessment documented and completed
SSKIN assessment completed
Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in Avatar)
Morse Fall Screening completed
Functional Screening done on Admission
Psychocial screening done on Admission
Nursing Notes timely documented using the standard Nursing Handover template in Epic
Nursing Care Plan timely documented
Patient Goals documented on Admission
Patient and Family Education
Patients preference list completed on admission
Shift Required documentation completed
Zero dots in Metrics (for this specific ) patient; Note: If metrics cannot be zeroed- justification must be entered timely in the metrics review

Sample 5

MRN
Ward/or Unit
Month
Nursing Assessment completed
Initial patient assessment (V/S, GCS, Risk Assessment Screening) timely documented (within two (2) hours from commencement of the shift and completed within 4 hours
Vital Signs timely documented
24 hours Intake and Output documented
Laboratory: Critical Laboratory and abnormal findings (Labs. and Imaging) escalated to Primary Team and documented
Patient contraptions (LDAs) assessed , bundle timely documented and completed
Purposeful Rounding timely done and completed
Daily Cares Safety completed
Device Cares Completed
Braden Scale=Pressure Injury Risk Assessment documented and completed
SSKIN assessment completed
Skin Impairments (Skin Lesion, Wound, Pressure Injury documented in Avatar)
Morse Fall Screening completed
Functional Screening done on Admission
Psychocial screening done on Admission
Nursing Notes timely documented using the standard Nursing Handover template in Epic
Nursing Care Plan timely documented
Patient Goals documented on Admission
Patient and Family Education
Patients preference list completed on admission
Shift Required documentation completed