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.