Template

CCNA Quality EPIC Documentation Audit Tool

by Mustafa Qaraqei, from the Community

This EPIC documentation audit tool supports ICU and critical care units in reviewing nursing records within the EMR. It covers admission and ongoing assessments, pain screening cadence, preprocedure nursing assessments, patient and family education planning, multidisciplinary care planning, and risk assessments for falls and VTE. The checklist prompts verification of restraint orders and monitoring, pressure injury risk using age appropriate Braden scales, central and peripheral line documentation, expected length of stay, discharge goals, and complete handover using ISBAR. Knowledge checks reinforce line reconciliation, consent requirements, and key KFMC policy references to improve documentation quality and compliance.

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Confirm accountability and compliance with a digital log

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions .

Template

NNI QT Nursing Documentation Audit Tool

This nursing documentation audit tool supports quality and compliance checks across inpatient care. It helps confirm adult nursing assessments are completed on time, including vital signs, Glasgow Coma Scale and risk screening within required time frames. Review intake and output records, escalation of abnormal laboratory and imaging results to the primary team, and assessment of lines drains and airways with bundle documentation. Validate purposeful rounding, daily care safety and device care. Check pressure injury risk with the Braden Scale, complete SSKIN assessments, and record skin impairments in the Avatar system. Confirm fall risk screening with the Morse Scale, functional and psychosocial screening on admission, and timely nursing notes using the Epic handover template. Ensure care plans and patient goals are documented, education is provided, preferences are recorded, and shift documentation is complete.

by Inn Ymedaca, from the Community

10+

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Template

Nursing Documentation Audit Checklist

Use this nursing documentation audit template to review the completeness, timeliness, and accuracy of patient records. Assess Braden Scale and SSKIN entries, skin impairment notes, vital signs, lines drains and airways, intake and output, escalation of critical labs and imaging, initial assessments, nursing handover notes in Epic, care plans, patient goals, education, functional and psychosocial screenings, and shift required documentation. Support compliance, improve care quality, and standardize charting across teams.

by Maria Asuncion Villanueva, from the Community

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Template

Nursing Documentation Audit Tool

This Nursing Documentation Audit Tool helps hospitals and clinical teams review the completeness and timeliness of nursing records. It covers initial assessments (vitals, GCS, risk screening), 24-hour intake and output, escalation and documentation of critical labs and abnormal findings, LDA device assessments and bundles, purposeful rounding, daily safety and device cares, Braden pressure injury risk, SSKIN, and documentation of skin impairments. It also checks Morse Fall risk, functional and psychosocial screenings on admission, standardized nursing notes and handover, nursing care plans and patient goals, patient and family education, preference lists, and shift-required documentation, including metrics justification.

by Murni Binti, from the Community

20+

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Template

Electronic Medical Record Documentation Audit

This Electronic Medical Record Documentation Audit template helps hospitals and clinics review the completeness and quality of clinical documentation across key areas of care. It covers consent validation, fall and pressure injury risk screening, pain assessment, social work and nutrition screening, patient and family education, timely medication administration, structured ISBAR handovers, nursing assessment and care planning, blood and blood product administration, discharge planning, and management of patient belongings. Use it to standardize audits, identify gaps, and strengthen compliance, documentation accuracy, and patient safety.

by Marnelli Ignacio, from the Community

30+

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Template

NNI Nursing Documentation Audit

This NNI Nursing Documentation Audit helps evaluate the completeness and timeliness of core nursing charting. Review pressure injury risk (Braden) and SSKIN bundle, skin impairments, vital signs, lines/drains/airways (LDAs) and bundles, 24-hour intake and output, and escalation of abnormal labs or imaging to the primary team. Confirm initial assessments within required timeframes, standardized nursing handover notes in Epic, active nursing care plans, patient goals on admission, education provided, functional and psychosocial screenings, preference lists, and shift-required documentation metrics. Use this checklist to standardize audits, identify gaps, and strengthen patient safety and regulatory compliance.

by Maria Asuncion Villanueva, from the Community

20+

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Template

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).

by SafetyCulture

1,000+

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CCNA Quality EPIC Documentation Audit Tool

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