Nursing audit checklist
Nursing audit is the process of determining the quality of nursing care by reviewing clinical records made by healthcare professionals. it helps ensure consistent quality patient care and uncover areas for improvement. use this nursing audit checklist to confirm compliance with proper nursing documentation and check patient care provided to patients (currently in admission or discharged).
What does this form include?
This form contains 12 sections:
Medical Record
- Admission assessment is fully completed, signed by RN (co-sign).
- All other assessments done: pain, fall, skin, etc.
- Treatment admin. records signed for.
- Medication admin. records (MAR) signed.
- Immunizations documented properly/done.
- Weights charted monthly per order.
Does the documentation demonstrate:
Is the care plan:
Thickened liquids/dysphagia
Special Needs
- Proper notation by the door (if permitted by state); proper protocol followed.
- Water at bedside.
Fall risks
Wounds
Pain management
Equipment in room
Resident appearance
Comments/Suggestions
Auditor name and signature
Use this template