Template

NQMA Pressure Injury Audit

10+

Use the NQMA Pressure Injury Audit HAPI tool to standardize bedside reviews of pressure injury risk and care. The checklist guides auditors through initial and shift based risk assessments, confirmation of prevention measures for at risk patients, and detailed documentation of hospital acquired and community acquired pressure injuries by stage and location. Ward and unit selectors support audits across ICU, surgical, medical, maternity, pediatric, and rehabilitation units. Capture patient identifiers where permitted, verify compliance within 24 hours of admission, and track trends to improve patient safety and quality of care.

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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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Template

NQMA - Pressure Injury Audit

Streamline hospital pressure injury monitoring with this NQMA Pressure Injury Audit template. Capture ward and unit details, patient identifiers, and verify completion of risk assessments within 24 hours and during the last shift. Identify patients at risk, check that preventive measures are implemented, and record HAPI and CAPI stages, locations, and counts. Suitable for nursing, ICU, rehab, and specialty units, this tool supports consistent documentation and patient safety compliance across the facility.

by Benson F, from the Community

10+

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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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Template

Electronic Medical Record Documentation Audit

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.

by Marnelli Ignacio, from the Community

30+

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Template

Inpatient Leadership Rounds Checklist

This inpatient leadership rounds checklist helps hospital leaders structure and document rounding on inpatient units. It covers security and safety checks, fire safety readiness, hazardous materials and waste handling, infection prevention and control standards, medical equipment maintenance, and emergency procedures. Clinical care observations include central line and urinary catheter care, ventilator care, falls risk, pressure injury prevention, and restraint documentation. Use this template to record findings, engage staff and patients, assign and track corrective actions, and demonstrate compliance with hospital policies and patient safety goals. Adapt sections to your unit and schedule regular reviews to drive continuous improvement.

by Alyson Estwick Morris, from the Community

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Template

CCNA Quality EPIC Documentation Audit Tool

This EPIC documentation audit tool supports ICU and critical care units in reviewing nursing records within the EMR. It covers admission and ongoing assessments, pain screening cadence, preprocedure nursing assessments, patient and family education planning, multidisciplinary care planning, and risk assessments for falls and VTE. The checklist prompts verification of restraint orders and monitoring, pressure injury risk using age appropriate Braden scales, central and peripheral line documentation, expected length of stay, discharge goals, and complete handover using ISBAR. Knowledge checks reinforce line reconciliation, consent requirements, and key KFMC policy references to improve documentation quality and compliance.

by Mustafa Qaraqei, from the Community

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Template

Wound Care Inpatient Audit

This Wound Care Inpatient Audit template helps hospitals and clinics evaluate wound care practices for admitted patients. Use it to confirm assessments within 24 hours, stage skin injuries, monitor HAPI and CAPI, document Q2-hour turns and pressure care, and verify nursing interventions for high-risk areas. The checklist supports reporting to physicians, patient and family education, and referrals to nutrition and rehab services, driving consistent documentation and better outcomes.

by Alyson Estwick Morris, from the Community

10+

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NQMA Pressure Injury Audit

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NQMA - Pressure Injury Audit

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NQMA - Pressure Injury Audit

HAPI Prevention Checklist

Electronic Medical Record Documentation Audit

Inpatient Leadership Rounds Checklist

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