Template

Wound Care Inpatient Audit

by Alyson Estwick Morris, from the Community

10+

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.

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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
Nursing Audit Checklist
This Nursing Audit Checklist helps healthcare teams evaluate the quality of nursing care through thorough review of clinical records and documentation. Confirm completion of admission assessments, MAR and treatment records, immunizations, and monthly weight charts. Assess the care plan for accuracy, measurable goals, relevant problems, interventions, follow-ups, and signatures. Review monitoring of vitals, skin, nutrition, hydration, mental status, and mobility. Include checks for dysphagia protocols, fall risks, wound and pain management, equipment labeling, and patient appearance.
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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
Downloads: 0
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Environment of Care Checklist for Inpatient Units
This inpatient environment of care checklist helps hospitals and behavioral health units assess safety, cleanliness, and compliance across entry and lobby areas, exam rooms, patient rooms, bathrooms, seclusion and restraint rooms, kitchens, laundry, storage, utilities, and exterior spaces. Use it to verify equipment inspections, temperature logs, secure areas, hazardous waste handling, and overall facility conditions.
by Shannon Seifreit, from the Community
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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+
Get

Nursing Audit Checklist

This Nursing Audit Checklist helps healthcare teams evaluate the quality of nursing care through thorough review of clinical records and documentation. Confirm completion of admission assessments, MAR and treatment records, immunizations, and monthly weight charts. Assess the care plan for accuracy, measurable goals, relevant problems, interventions, follow-ups, and signatures. Review monitoring of vitals, skin, nutrition, hydration, mental status, and mobility. Include checks for dysphagia protocols, fall risks, wound and pain management, equipment labeling, and patient appearance.

by Ghada Karawi, from the Community

10+

Get

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

Get

Template

Environment of Care Checklist for Inpatient Units

This inpatient environment of care checklist helps hospitals and behavioral health units assess safety, cleanliness, and compliance across entry and lobby areas, exam rooms, patient rooms, bathrooms, seclusion and restraint rooms, kitchens, laundry, storage, utilities, and exterior spaces. Use it to verify equipment inspections, temperature logs, secure areas, hazardous waste handling, and overall facility conditions.

by Shannon Seifreit, from the Community

Get

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

10+

Get

Wound Care Inpatient Audit

About author

You might also like

Nursing Audit Checklist

Inpatient Leadership Rounds Checklist

Environment of Care Checklist for Inpatient Units

NNI QT Nursing Documentation Audit Tool

You might also like

Nursing Audit Checklist

Inpatient Leadership Rounds Checklist

Environment of Care Checklist for Inpatient Units

NNI QT Nursing Documentation Audit Tool