Template

NNI Nursing Documentation Audit

by Maria Asuncion Villanueva, from the Community

20+

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.

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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
Nursing Documentation Audit Checklist
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.
by Maria Asuncion Villanueva, from the Community
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Template
NNI Nursing Documentation Audit Checklist
Ensure accurate and timely nursing records with this NNI Nursing Documentation Audit. Review vital signs, risk assessments, LDAs, intake and output, lab escalation, initial assessments, nursing handover notes, care plans, patient goals, education, psychosocial and functional screenings, preferences, and shift documentation. Use it to standardize charting, support compliance, and improve patient safety.
by Maria Asuncion Villanueva, from the Community
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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
Downloads: 10+
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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+
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NNI Nursing Documentation Audit

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