Template

Nursing Documentation Audit Checklist

by Maria Asuncion Villanueva, from the Community

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.

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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
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
Downloads: 20+
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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
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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
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Template
HAPI Prevention Checklist
Use this Hospital-Acquired Pressure Injury (HAPI) checklist to standardize prevention and documentation at the bedside. It guides Braden risk assessments on admission and each shift, baseline and periodic photos, Risk Connect reporting for Braden scores under 15, partial bath and perineal care every 4 hours, daily foot care, use of an airflow mattress, frequent diaper checks, turning and pressure care every 2 hours with a 30-degree foam wedge, and patient and family education. Adapt to your facility policy.
by Virdinia King, from the Community
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Nursing Documentation Audit Checklist

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NNI Nursing Documentation Audit

Nursing Documentation Audit Tool

Nursing Audit Checklist

HAPI Prevention Checklist

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NNI Nursing Documentation Audit

Nursing Documentation Audit Tool

Nursing Audit Checklist

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