Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Patient Details

  • Patient Name

  • Marital Status

  • Date of birth

  • Ethnic background

  • Religion

  • Place of birth

  • Current address

  • Preferred name

  • NHS number

  • Next of kin and relationship

  • Next of kin address and telephone number

  • Care manager and details

PHYSICAL NEEDS

  • Overview of medical history and current physical diagnosis

  • Current medication

  • Allergies

  • Elimination needs

  • Breathing

  • Sleeping

  • Waterloo score

  • Skin integrity

  • Pain

  • Sight

  • Hearing

Psychiatric diagnosis (present day and history)

  • Communication

  • Mental health presentation

Abilities and risks

  • Personal hygiene and dressing (and possibility of self neglect)

  • Eating and drink (including associated risks)

  • Mobility and associated risks (falls risk)

  • Social abilities and associated risks (behaviours that may effect others)

Spiritual needs

  • Religious and spiritual requirement including diet and prayer

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.