Audit

This audit collects patient level data on a ward/unit. Start a new audit for each patient audited.

If an unwanted media field opens, tap the relevant question to close it.

Please maintain patient confidentiality at all times.

Observational audit - patient
Which type of bed rail is present on the bed? (Note: only check where a patient is present.)

Is the nurse call system within reach of the patient?

Is the bed control (if bed has a control) within reach of the patient?

Is the patient's bed at the appropriate height? Note: Appropriate height is the level that the patient can sit and touch the floor with their feet, with their legs at 90 degrees.

Are the patient's bed brakes locked on?

Is the patient's chair at the appropriate height?

Is the patient's room free of clutter / other hazards?

Is the patient's tray table within reach?

If the patient has sensory aids (eg glasses, hearing aid) are they within reach?

Does the patient have appropriate footwear? (Eg non-slip / well fitting / low heel)

If patient is at risk of falling, are they within view of and close to the nursing station? (Risk is determined below.)

If "no" responses are obtained, advise Nurse so that the problem can be promptly rectified.

Documentation audit - patient

Is there documented evidence at the bedside that the patient was screened for a history of falling on admission?
(Note: screening identifies if the patient is at increased risk of falling and then should be assessed at admission.)

Is there documented evidence at the bedside that the patient was assessed for risk of falling on admission?

What is the patient's documented risk of falling?

What type of bed is the patient in?

If the patient is at risk of falling, have they been reviewed by the Physio / OT?

Which one?,

Is there documented evidence at the bedside that there is a multifactorial falls prevention plan (FPP)?
(Ie documented actions corresponding to identified risk factors.)

What type of bed is the patient in?

Is there documented evidence at the bedside of the level of supervision / assistance required for mobilisation in the patient's care plan? (Red dot system.)
(N/A for patients that can mobilise independently.)

Is there documented evidence at the bedside that the patient's care plan includes the use of a mobility aid?
(N/A for patients that can mobilise independently.)

Is the mobility aid within arms reach of the patient? (Patient refuses to use aid = PRTUA)

Does the patient have documentation at the bedside (ie in the care plan) that an assessment has been undertaken for continence and continence aid requirements?

Has the discharge process commenced?

Have referrals to appropriate primary health providers / community services been organised?

To whom - select all applicable options

Specify what other referrals have been made.

Is there evidence that the patient has experienced a fall while in hospital?

Is there evidence the incident has been entered into the incident management system (EIMS)?

Report to NUM to ensure incident is recorded.

Patient Questions

Patient Q: We're you shown around the bed area, room and ward/unit facilities on admission?

Patient Q: Did you have an education session with a staff member on how you can prevent falls?

Which form of education did you receive?

Patient Q: Were you involved in the development of plans to prevent you falling while in hospital?

If you have identified a patient risk related to bed or surrounds, please photograph here (do not include any patient faces in the photo).
Auditor please enter your name and sign off here
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.