Template

Procedural Sedation Documentation Audit

by Nora Abdul Rahman, from the Community

This procedural sedation documentation audit checklist helps clinical teams ensure complete and compliant records across the entire care pathway. Use it to review pre-procedural requirements such as allergy acknowledgement, consent completion, and fall risk and pain assessments. During procedures, confirm time-out completion, capture vital signs at regular intervals, and record anticipations or events in notes. Post-procedure, review sign-out, continue vital sign and GCS monitoring, update fall risk, reassess pain, and finalize the nursing care plan and transfer or discharge assessment. Designed for healthcare settings to standardize documentation and support patient safety and quality of care.

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

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
ED Assessment and Documentation Audit v.2
This Emergency Department assessment and documentation audit checklist helps nurses and clinicians review chart quality and compliance. It covers patient identification, CTAS and acuity selection, physical assessment and reassessment, medication administration and dual sign-off, SMART nursing care plans, fall risk screening and prevention, pain assessment and management using approved tools, nutritional screening and referrals, patient and family education, social worker screening, LDA and wound documentation, skin and pressure injury prevention, intake and output, POCT workflows, procedural checklists without sedation, consent verification, handover using ISBAR, critical result documentation, blood and blood product administration, and safeguarding patient belongings. Use this tool to standardize ED documentation, strengthen safety, and support policy adherence.
by Nora Abdul Rahman, from the Community
Downloads: 0
Get
Template
Inpatient Unit Tracer
This comprehensive healthcare documentation guide outlines essential compliance requirements and protocols for medical facilities. It covers critical areas including pre-operative documentation, anesthesia assessments, surgical procedures, nursing care, and safety protocols. The guide details specific requirements for patient documentation, including H&P updates, informed consent, time-out procedures, and post-operative notes. It also addresses important nursing documentation requirements such as care plans, medication management, fall protocols, and advance directives. Additionally, the guide includes vital safety and compliance measures for equipment handling, infection control, medication storage, and emergency preparedness. This resource serves as a complete reference for healthcare providers to maintain regulatory compliance and ensure high-quality patient care documentation.
by Tameria Joy, from the Community
Downloads: 50+
Get
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
Downloads: 30+
Get
Template
JHH OR and Procedure Tracer
This document outlines comprehensive guidelines for surgical and procedural documentation in healthcare settings. It covers essential requirements for patient safety and medical record keeping, including pre-operative documentation, H&P updates, informed consent procedures, anesthesia protocols, and post-operative documentation standards. The guidelines detail specific timeframes for documentation completion, safety protocols such as site marking and time-out procedures, medication handling requirements, and post-anesthesia evaluation criteria. It also includes requirements for immediate and detailed post-operative notes, discharge documentation, and equipment handling procedures. These standards ensure compliance with healthcare regulations while maintaining patient safety and proper medical record documentation.
by Aileen Almario, from the Community
Downloads: 70+
Get

Procedural Sedation Documentation Audit

About author

You might also like

ED Assessment and Documentation Audit v.2

Inpatient Unit Tracer

Electronic Medical Record Documentation Audit

JHH OR and Procedure Tracer

You might also like

ED Assessment and Documentation Audit v.2

Inpatient Unit Tracer

Electronic Medical Record Documentation Audit

JHH OR and Procedure Tracer