Template

Electronic Medical Record Documentation Audit

by Marnelli Ignacio, from the Community

30+

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.

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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
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: 0
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Template
ED Assessment and Documentation Audit Checklist
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.
by Nora Abdul Rahman, from the Community
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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
Downloads: 10+
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Template
JCI Mock Survey Tools
Use these JCI mock survey tools to evaluate hospital readiness against Joint Commission International standards. The checklist covers International Patient Safety Goals, Access to Care and Continuity of Care, Patient and Family Rights, Assessment and Care of Patients, Patient and Family Education, and Management of Information. Verify patient identification, safe medication practices, hand hygiene, surgical safety, fall risk, consent, discharge, transfers, and documentation. Identify compliance gaps, standardize handovers, confirm critical results workflows, and ensure secure information management and record retention. Ideal for internal audits, staff training, and accreditation preparation.
by mohamed elgamal, from the Community
Downloads: 10+
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Electronic Medical Record Documentation Audit

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ED Assessment and Documentation Audit v.2

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ED Assessment and Documentation Audit v.2

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