Open File Audit

• MICU ,CCU, CTICU, LTICU, 6th Floor, 7th Floor

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Case sheet has admission slip?

  Yes

  No

  N/A

• In case ER, Is Dr.Initial Assessment complete

  Yes

  No

  N/A

• Triage form completed?

  Yes

  No

  N/A

• ER Nurses Notes completed

  Yes

  No

  N/A

• ER - Fall Risk, Skin assessment, Pain assessment complete

  Yes

  No

  N/A

• ER - Drug orders, Investigation orders details completed

  Yes

  No

  N/A

• ER Transfer Summary Completed

  Yes

  No

  N/A

• Reconciliation of Drugs completed

  Yes

  No

  N/A

• Ward / ICU Dr.Initial assessment completed

  Yes

  No

  N/A

• Ward / ICU Nurses Initial assessment completed?

  Yes

  No

  N/A

• Progress Reports properly labelled, dated, Timed & signed

  Yes

  No

  N/A

• Nurses daily Assessment- Fall, Braden, Mews, Patient Education I/O, Vitals chart properly labelled , documented

  Yes

  No

  N/A

• Is Investigation chart present & Documented legibly

  Yes

  No

  N/A

• Diabetic chart documented legibily

  Yes

  No

  N/A

• Medication chart written as per prescription

  Yes

  No

  N/A

• Nurses reports properly labelled, dated, Timed & Signed

  Yes

  No

  N/A

• Nutritional Screening done properly in admission

  Yes

  No

  N/A

• Nutritional Assessment by Dietician is happened

  Yes

  No

  N/A

• If surgical Management surgical booklet is completed

  Yes

  No

  N/A

• Billing Card updated properly

  Yes

  No

  N/A

undefined

• Yes

  No

  N/A