Template

NQMA - Pressure Injury Audit

by Benson F, from the Community

10+

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.

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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

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

About author

Community

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
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
Downloads: 0
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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: 20+
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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 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
Downloads: 1,000+
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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

Get

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

20+

Get

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

20+

Get

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

1,000+

Get

NQMA - Pressure Injury Audit

About author

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HAPI Prevention Checklist

Nursing Documentation Audit Tool

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