Template

Triage Documentation Audit Checklist

by Nora Abdul Rahman, from the Community

This triage documentation audit checklist helps emergency departments review and improve the accuracy and completeness of triage records. It covers fall risk screening, pain assessment and reassessment, sepsis screening aligned with clinical pathways, triage acuity, consent, chief complaints, height and weight, allergy checks, home medication review, and patient history. It also prompts reassessment of vital signs when indicated and supports better compliance, care planning, and patient safety.

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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
Visual Triage Supply Availability Checklist
This template supports infection prevention teams by tracking the availability of visual triage requirements in healthcare settings. Based on guidance from Infection Prevention and Control in Jazan Health, it prompts checks for updated forms, surgical masks at triage tables, and hand hygiene supplies. Use it to verify readiness at intake points and maintain safe, compliant triage processes across clinics and hospitals.
by Ali Ashery, from the Community
Downloads: 10+
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Template
ED Assessment and Documentation Audit Checklist
This Emergency Department assessment and documentation audit checklist helps nurses and quality teams review the completeness and accuracy of ED records. It covers patient identification, medication administration, physical assessment, nursing care plans aligned with NANDA, fall risk screening, pain assessment and reassessment, nutritional screening, patient and family education, LDA and wound documentation, skin assessment and pressure injury prevention, POCT workflows, and provider communication and shift endorsements.
by Nora Abdul Rahman, from the Community
Downloads: 0
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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
Downloads: 30+
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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
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Triage Documentation Audit Checklist

With SafetyCulture you can

Digitize team workflows

Reduce manual errors

Create and share inspection reports

About author

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ED Assessment and Documentation Audit Checklist

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Visual Triage Supply Availability Checklist

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