Template

Comprehensive Chart Review Checklist

by Jill Muccino, from the Community

This comprehensive chart review checklist helps clinicians and quality teams evaluate the completeness and accuracy of patient records. It covers consent to treatment, intake documentation, care team details, problem list, vital signs, BMI, medications, immunizations, allergies, condition history, and pain management. It includes lab results, physical or psychiatric exam findings, preventative screenings, diabetes and asthma management, cardiovascular risk and hypertension, hepatitis C screening, tobacco use, pregnancy, and spiritual needs. Assess service and treatment plans, goals, social determinants of health, referrals, discharge, HPI, medical decision making, and documentation timeliness.

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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

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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
Medical Audit Checklist
This medical audit checklist helps healthcare teams evaluate the quality and completeness of clinical documentation and patient records. It covers electronic record security, author identification, demographics, allergies, history, and consent. Review diagnosis and management notes, medications and prescriptions, referrals and test tracking, screening history, immunizations, risk factors, and chronic disease monitoring. Use it to document follow-ups, ensure timely notifications, and verify care transfers for robust compliance and patient safety.
by Mikail Olabanji, from the Community
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ED Assessment and Documentation Audit v.2
This Emergency Department assessment and documentation audit checklist helps nurses and clinicians review chart quality and compliance. It covers patient identification, CTAS and acuity selection, physical assessment and reassessment, medication administration and dual sign-off, SMART nursing care plans, fall risk screening and prevention, pain assessment and management using approved tools, nutritional screening and referrals, patient and family education, social worker screening, LDA and wound documentation, skin and pressure injury prevention, intake and output, POCT workflows, procedural checklists without sedation, consent verification, handover using ISBAR, critical result documentation, blood and blood product administration, and safeguarding patient belongings. Use this tool to standardize ED documentation, strengthen safety, and support policy adherence.
by Nora Abdul Rahman, from the Community
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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
Downloads: 30+
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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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Comprehensive Chart Review Checklist

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Medical Audit Checklist

ED Assessment and Documentation Audit v.2

Electronic Medical Record Documentation Audit

Nursing Documentation Audit Checklist

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Medical Audit Checklist

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