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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About author
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.