Template

ED Assessment and Documentation Audit Checklist

by Nora Abdul Rahman, from the Community

This Emergency Department assessment and documentation audit checklist helps nurses and quality teams review the completeness and accuracy of ED records. It covers patient identification, medication administration, physical assessment, nursing care plans aligned with NANDA, fall risk screening, pain assessment and reassessment, nutritional screening, patient and family education, LDA and wound documentation, skin assessment and pressure injury prevention, POCT workflows, and provider communication and shift endorsements.

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

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
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
Downloads: 10+
Get
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
Downloads: 30+
Get
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
Downloads: 20+
Get
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
Downloads: 10+
Get

ED Assessment and Documentation Audit Checklist

About author

You might also like

ED Assessment and Documentation Audit v.2

Electronic Medical Record Documentation Audit

Nursing Documentation Audit Tool

NNI QT Nursing Documentation Audit Tool

You might also like

ED Assessment and Documentation Audit v.2

Electronic Medical Record Documentation Audit

Nursing Documentation Audit Tool

NNI QT Nursing Documentation Audit Tool