Nursing Audit

Updated: over a week ago

Nursing Audit

Medical Record

1. Admission assessment is fully completed, signed or co-signed by the Registered Nurse (RN)?


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2. Have all other assessments like pain, fall, skin, etc. been completed?


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3. Treatment administration records signed?


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4. Medication administration records (MAR) signed?


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5. Immunizations documented properly/done?


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6. Weights charted monthly per order?


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7. Does the documentation demonstrate skilled observation and monitoring?


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8. Does the documentation demonstrate assessment?


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9. Does the documentation demonstrate progress notes?


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10. What else does the documentation demonstrate?


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Care Plan

1. Is the care plan accurate and up to date?


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2. Does the care plan demonstrate measurable goals?


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3. Does the care plan address relevant problems?


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4. Are specific problems or potential problems and planned interventions identified?


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5. Does the care plan show an indication of daily or more frequent monitoring of vital signs, lung sounds, bowel sounds, skin condition, nutritional status, hydration, mental status, and mobility?


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6. Does the care plan display any instability or possible changes in the patient’s condition to help identify if changes in nursing care are indicated / required?


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7. Does the care plan show proper evaluation dates and follow-ups?


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8. Are there proper signatures on the care plan?


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9. Does the care plan reflect MDS and other assessments?


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10. Is the evidence of teaching, training and outcomes clearly noted?


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Thickened Liquids/dysphagia

1. Proper notation by the door (if permitted by legal guidelines); proper protocol followed?


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2. Water at bedside?


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Fall Risks

1. Is fall risk evident?


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2. Has appropriate care been planned?


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Wounds

1. Wound care protocol followed/proper forms completed?


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2. Has appropriate care been planned?


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Pain Management

1. Protocol/forms followed (assessment and outcome)?


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2. Has appropriate care been planned?


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3. Has MAR been completed?


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4. Have initial and ongoing pain assessments been done?


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Equipment In Room

1. Has respiratory, feeding pump equipment been labelled / tagged?


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2. Have IVs been dated and labelled?


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3. Have wound dressings, IV site been dated and signed?


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Resident Appearance

1. Has the resident been properly positioned (wheelchair or bed)?


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2. Does the resident appear clean with the appropriate dress?


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3. Any complaints/concerns?


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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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